Provider Demographics
NPI:1700342490
Name:WHEATLEY, PHILICIA LASHAUN
Entity Type:Individual
Prefix:
First Name:PHILICIA
Middle Name:LASHAUN
Last Name:WHEATLEY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10719 S CALUMET AVE APT 1S
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60628-3649
Mailing Address - Country:US
Mailing Address - Phone:773-507-7562
Mailing Address - Fax:
Practice Address - Street 1:847 N ROCKWELL ST # 2F
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60622-4553
Practice Address - Country:US
Practice Address - Phone:785-760-4705
Practice Address - Fax:844-308-7900
Is Sole Proprietor?:No
Enumeration Date:2019-02-18
Last Update Date:2019-02-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes222Q00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersDevelopmental Therapist