Provider Demographics
NPI:1134278062
Name:RUSS, PENNY (PTA)
Entity type:Individual
Prefix:
First Name:PENNY
Middle Name:
Last Name:RUSS
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 1:205 S PARK ST
Mailing Address - Street 2:
Mailing Address - City:STREATOR
Mailing Address - State:IL
Mailing Address - Zip Code:61364-4448
Mailing Address - Country:US
Mailing Address - Phone:815-673-1770
Mailing Address - Fax:815-673-1772
Practice Address - Street 1:205 S PARK ST
Practice Address - Street 2:
Practice Address - City:STREATOR
Practice Address - State:IL
Practice Address - Zip Code:61364-4448
Practice Address - Country:US
Practice Address - Phone:815-673-1770
Practice Address - Fax:815-673-1772
Is Sole Proprietor?:No
Enumeration Date:2007-01-09
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL14663601Medicare ID - Type Unspecified