Provider Demographics
NPI:1750106670
Name:ENRIQUEZ, TIMOTHY D (PTA)
Entity type:Individual
Prefix:
First Name:TIMOTHY
Middle Name:D
Last Name:ENRIQUEZ
Suffix:
Gender:M
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:23144 W MCCLINTOCK RD
Mailing Address - Street 2:
Mailing Address - City:CHANNAHON
Mailing Address - State:IL
Mailing Address - Zip Code:60410-3001
Mailing Address - Country:US
Mailing Address - Phone:773-218-1024
Mailing Address - Fax:
Practice Address - Street 1:23144 W MCCLINTOCK RD
Practice Address - Street 2:
Practice Address - City:CHANNAHON
Practice Address - State:IL
Practice Address - Zip Code:60410-3001
Practice Address - Country:US
Practice Address - Phone:773-218-1024
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-11-15
Last Update Date:2024-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL160.008444225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant