Provider Demographics
NPI:1902017908
Name:PELLACK, ALTHEA M (PT)
Entity Type:Individual
Prefix:
First Name:ALTHEA
Middle Name:M
Last Name:PELLACK
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1630 KIWI AVE
Mailing Address - Street 2:
Mailing Address - City:BOONE
Mailing Address - State:IA
Mailing Address - Zip Code:50036-7146
Mailing Address - Country:US
Mailing Address - Phone:515-275-4977
Mailing Address - Fax:
Practice Address - Street 1:950 OFFICE PARK RD
Practice Address - Street 2:SUITE 100
Practice Address - City:WEST DES MOINES
Practice Address - State:IA
Practice Address - Zip Code:50265-2549
Practice Address - Country:US
Practice Address - Phone:515-224-0979
Practice Address - Fax:515-223-3862
Is Sole Proprietor?:No
Enumeration Date:2007-05-24
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA02386225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist