Provider Demographics
NPI:1902231855
Name:DE SIMONE, LORI (PTA)
Entity Type:Individual
Prefix:
First Name:LORI
Middle Name:
Last Name:DE SIMONE
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2634 GLENN ST
Mailing Address - Street 2:
Mailing Address - City:BETTENDORF
Mailing Address - State:IA
Mailing Address - Zip Code:52722-3824
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2634 GLENN ST
Practice Address - Street 2:
Practice Address - City:BETTENDORF
Practice Address - State:IA
Practice Address - Zip Code:52722-3824
Practice Address - Country:US
Practice Address - Phone:707-703-9729
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-09-11
Last Update Date:2013-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL160.006322225200000X
CAAT 6448225200000X
IA00802225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant