Provider Demographics
NPI:1245360296
Name:POTTER, ELEANOR (PT)
Entity type:Individual
Prefix:
First Name:ELEANOR
Middle Name:
Last Name:POTTER
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:770 BUSSE HWY
Mailing Address - Street 2:SUITE C
Mailing Address - City:PARK RIDGE
Mailing Address - State:IL
Mailing Address - Zip Code:60068-2441
Mailing Address - Country:US
Mailing Address - Phone:847-384-6804
Mailing Address - Fax:847-384-6806
Practice Address - Street 1:770 BUSSE HWY
Practice Address - Street 2:SUITE C
Practice Address - City:PARK RIDGE
Practice Address - State:IL
Practice Address - Zip Code:60068-2441
Practice Address - Country:US
Practice Address - Phone:847-384-6804
Practice Address - Fax:847-384-6806
Is Sole Proprietor?:No
Enumeration Date:2007-03-07
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL070004923225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILK14844Medicare ID - Type Unspecified