Provider Demographics
NPI:1184159576
Name:HARTY, PADRAIC
Entity type:Individual
Prefix:
First Name:PADRAIC
Middle Name:
Last Name:HARTY
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1430 TRUMBULL AVE
Mailing Address - Street 2:APARTMENT 2
Mailing Address - City:NORMAL
Mailing Address - State:IL
Mailing Address - Zip Code:61761-9488
Mailing Address - Country:US
Mailing Address - Phone:708-305-0690
Mailing Address - Fax:
Practice Address - Street 1:1430 TRUMBULL AVE
Practice Address - Street 2:APT 2
Practice Address - City:NORMAL
Practice Address - State:IL
Practice Address - Zip Code:61761-9488
Practice Address - Country:US
Practice Address - Phone:708-305-0690
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-04-24
Last Update Date:2017-09-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL246Z00000X
IL0960045042255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic TrainerGroup - Multi-Specialty
No246Z00000XTechnologists, Technicians & Other Technical Service ProvidersSpecialist/Technologist, OtherGroup - Multi-Specialty