Provider Demographics
NPI:1023496395
Name:SUPERSON, DANUTA B (LMT)
Entity type:Individual
Prefix:MS
First Name:DANUTA
Middle Name:B
Last Name:SUPERSON
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:763 DOVER PL
Mailing Address - Street 2:
Mailing Address - City:WHEELING
Mailing Address - State:IL
Mailing Address - Zip Code:60090
Mailing Address - Country:US
Mailing Address - Phone:773-501-0306
Mailing Address - Fax:
Practice Address - Street 1:8364 W GRAND AVE
Practice Address - Street 2:
Practice Address - City:RIVER GROVE
Practice Address - State:IL
Practice Address - Zip Code:60171
Practice Address - Country:US
Practice Address - Phone:708-452-5686
Practice Address - Fax:708-452-1648
Is Sole Proprietor?:No
Enumeration Date:2015-05-07
Last Update Date:2015-05-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL227000934225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist