Provider Demographics
NPI:1255426219
Name:DHOM, LAURA E (PT)
Entity type:Individual
Prefix:MRS
First Name:LAURA
Middle Name:E
Last Name:DHOM
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 1:1180 W. WILSON ST., SUITE B
Mailing Address - Street 2:
Mailing Address - City:BATAVIA
Mailing Address - State:IL
Mailing Address - Zip Code:60510
Mailing Address - Country:US
Mailing Address - Phone:630-406-1800
Mailing Address - Fax:630-406-1805
Practice Address - Street 1:1180 W. WILSON ST., SUITE B
Practice Address - Street 2:
Practice Address - City:BATAVIA
Practice Address - State:IL
Practice Address - Zip Code:60510
Practice Address - Country:US
Practice Address - Phone:630-406-1800
Practice Address - Fax:630-406-1805
Is Sole Proprietor?:No
Enumeration Date:2006-10-04
Last Update Date:2019-08-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL070.008799225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL04520794OtherBCBS PIN #
ILK34535Medicare ID - Type UnspecifiedMEDICARE PROVIDER NUMBER
IL214636Medicare ID - Type UnspecifiedMEDICARE GROUP NUMBER