Provider Demographics
NPI:1265769988
Name:MCCANN, ANTONIA (PT)
Entity type:Individual
Prefix:
First Name:ANTONIA
Middle Name:
Last Name:MCCANN
Suffix:
Gender:
Credentials:PT
Other - Prefix:
Other - First Name:ANTONIA
Other - Middle Name:
Other - Last Name:HENRY-CAMPOS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PT
Mailing Address - Street 1:2001 BUTTERFIELD RD STE 1600
Mailing Address - Street 2:
Mailing Address - City:DOWNERS GROVE
Mailing Address - State:IL
Mailing Address - Zip Code:60515-1211
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:12052 S CICERO AVE
Practice Address - Street 2:
Practice Address - City:ALSIP
Practice Address - State:IL
Practice Address - Zip Code:60803-2313
Practice Address - Country:US
Practice Address - Phone:708-489-9940
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-11-17
Last Update Date:2025-03-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILP01023350OtherMEDICARE RR
ILP01023350OtherMEDICARE RR