Provider Demographics
NPI:1891736542
Name:LAUREANO, MYRNA I (PTA)
Entity Type:Individual
Prefix:MRS
First Name:MYRNA
Middle Name:I
Last Name:LAUREANO
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:MRS
Other - First Name:MYRNA
Other - Middle Name:I
Other - Last Name:RIVERA
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:PTA
Mailing Address - Street 1:5TH AND ROOSEVELT ROAD
Mailing Address - Street 2:PHYSICAL THERAPY DEPARTMENT 117G
Mailing Address - City:HINES
Mailing Address - State:IL
Mailing Address - Zip Code:60641
Mailing Address - Country:US
Mailing Address - Phone:708-202-8387
Mailing Address - Fax:
Practice Address - Street 1:5TH AVE AND ROOSEVELT ROAD
Practice Address - Street 2:PHYSICAL THERAPY DEPARTMENT 117G
Practice Address - City:HINES
Practice Address - State:IL
Practice Address - Zip Code:60641
Practice Address - Country:US
Practice Address - Phone:708-202-8387
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-06-10
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR00124225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant