Provider Demographics
NPI:1942879085
Name:CHAU, RODDARA (PTA)
Entity Type:Individual
Prefix:
First Name:RODDARA
Middle Name:
Last Name:CHAU
Suffix:
Gender:M
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:472 N SUGAR GROVE PKWY
Mailing Address - Street 2:SUITE F #107
Mailing Address - City:SUGAR GROVE
Mailing Address - State:IL
Mailing Address - Zip Code:60554
Mailing Address - Country:US
Mailing Address - Phone:630-819-0086
Mailing Address - Fax:
Practice Address - Street 1:1212 S 2ND ST
Practice Address - Street 2:
Practice Address - City:DEKALB
Practice Address - State:IL
Practice Address - Zip Code:60115-4435
Practice Address - Country:US
Practice Address - Phone:815-758-8151
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-06-23
Last Update Date:2021-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL160.008295225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant