Provider Demographics
NPI:1013168319
Name:WALLACE-ROBINSON, YVONNE D (PTA)
Entity Type:Individual
Prefix:
First Name:YVONNE
Middle Name:D
Last Name:WALLACE-ROBINSON
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 1:2225 FOSTER ST
Mailing Address - Street 2:
Mailing Address - City:EVANSTON
Mailing Address - State:IL
Mailing Address - Zip Code:60201-3353
Mailing Address - Country:US
Mailing Address - Phone:847-424-9784
Mailing Address - Fax:
Practice Address - Street 1:2225 FOSTER ST
Practice Address - Street 2:
Practice Address - City:EVANSTON
Practice Address - State:IL
Practice Address - Zip Code:60201-3353
Practice Address - Country:US
Practice Address - Phone:847-424-9784
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-10-05
Last Update Date:2008-10-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL160004154225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant