Provider Demographics
NPI:1942712914
Name:RAISI, SIMONE (PT)
Entity Type:Individual
Prefix:
First Name:SIMONE
Middle Name:
Last Name:RAISI
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 1:790 REMINGTON BLVD
Mailing Address - Street 2:
Mailing Address - City:BOLINGBROOK
Mailing Address - State:IL
Mailing Address - Zip Code:60440-4909
Mailing Address - Country:US
Mailing Address - Phone:630-296-2223
Mailing Address - Fax:630-759-9510
Practice Address - Street 1:8843 BRANCH AVE
Practice Address - Street 2:
Practice Address - City:CLINTON
Practice Address - State:MD
Practice Address - Zip Code:20735-2632
Practice Address - Country:US
Practice Address - Phone:301-888-8003
Practice Address - Fax:301-754-0739
Is Sole Proprietor?:No
Enumeration Date:2017-10-31
Last Update Date:2020-05-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD26497225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist