Provider Demographics
NPI:1922205178
Name:PROFESSIONAL PHYSICAL THERAPY SERVICES, P.C.
Entity Type:Organization
Organization Name:PROFESSIONAL PHYSICAL THERAPY SERVICES, P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:VICE PRESIDENT
Authorized Official - Prefix:MS
Authorized Official - First Name:CHRISTY
Authorized Official - Middle Name:M
Authorized Official - Last Name:OLOFSSON
Authorized Official - Suffix:
Authorized Official - Credentials:OTR, PTA
Authorized Official - Phone:773-779-7273
Mailing Address - Street 1:10201 S WESTERN AVE
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60643-1917
Mailing Address - Country:US
Mailing Address - Phone:773-779-7273
Mailing Address - Fax:773-779-7298
Practice Address - Street 1:10201 S WESTERN AVE
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60643-1917
Practice Address - Country:US
Practice Address - Phone:773-779-7273
Practice Address - Fax:773-779-7298
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-06-29
Last Update Date:2010-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL070000479225100000X
IL070012996225100000X
IL160004410225200000X
IL056002420225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistGroup - Multi-Specialty
No225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Multi-Specialty
No225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy AssistantGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL0001618872OtherBC BS OF IL
IL650004791OtherR.R. MEDICARE
IL0001618872OtherBC BS OF IL