Provider Demographics
NPI:1972167328
Name:DONALDSON, ELIZABETH (PTA)
Entity Type:Individual
Prefix:MRS
First Name:ELIZABETH
Middle Name:
Last Name:DONALDSON
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 1:10000 S MAIN ST
Mailing Address - Street 2:
Mailing Address - City:CHATHAM
Mailing Address - State:IL
Mailing Address - Zip Code:62629-7400
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:10000 S MAIN ST
Practice Address - Street 2:
Practice Address - City:CHATHAM
Practice Address - State:IL
Practice Address - Zip Code:62629-7400
Practice Address - Country:US
Practice Address - Phone:217-622-1082
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-04-30
Last Update Date:2019-04-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL160005788225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL160005788OtherSTATE OF ILLINOIS PTA LICENSE