Provider Demographics
NPI:1891828141
Name:DEFREES, PAULA M (PHYSICAL THERAPIST)
Entity Type:Individual
Prefix:
First Name:PAULA
Middle Name:M
Last Name:DEFREES
Suffix:
Gender:F
Credentials:PHYSICAL THERAPIST
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1107 N MARION ST
Mailing Address - Street 2:
Mailing Address - City:OAK PARK
Mailing Address - State:IL
Mailing Address - Zip Code:60302-1252
Mailing Address - Country:US
Mailing Address - Phone:708-763-5540
Mailing Address - Fax:708-383-2324
Practice Address - Street 1:70-078 COUNTRY CLUB DR.
Practice Address - Street 2:SUITE 205
Practice Address - City:BERMUDA DUNES
Practice Address - State:CA
Practice Address - Zip Code:92203
Practice Address - Country:US
Practice Address - Phone:760-345-9934
Practice Address - Fax:760-345-3086
Is Sole Proprietor?:No
Enumeration Date:2007-03-14
Last Update Date:2012-03-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL070-005572208100000X
CAPT38729225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
No208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL140049OtherMEDICARE GROUP NUMBER
CAPT38729Medicare UPIN