Provider Demographics
NPI:1922631142
Name:THATTE, SAMPADA
Entity Type:Individual
Prefix:
First Name:SAMPADA
Middle Name:
Last Name:THATTE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2535 BODDINGTON LN
Mailing Address - Street 2:
Mailing Address - City:NAPERVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:60564-9487
Mailing Address - Country:US
Mailing Address - Phone:630-806-5564
Mailing Address - Fax:
Practice Address - Street 1:219 PARKWAY DR
Practice Address - Street 2:
Practice Address - City:WHEATON
Practice Address - State:IL
Practice Address - Zip Code:60187-3651
Practice Address - Country:US
Practice Address - Phone:630-528-2070
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-02-17
Last Update Date:2020-02-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL160006437225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant