Provider Demographics
NPI:1669740577
Name:MONTALVO, GUILLERMINA (PTA)
Entity type:Individual
Prefix:MRS
First Name:GUILLERMINA
Middle Name:
Last Name:MONTALVO
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 1:5416 S KILBOURN AVE
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60632-4730
Mailing Address - Country:US
Mailing Address - Phone:773-983-4220
Mailing Address - Fax:
Practice Address - Street 1:5416 S KILBOURN AVE
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60632-4730
Practice Address - Country:US
Practice Address - Phone:773-983-4220
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-12-06
Last Update Date:2011-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL160.002988225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant