Provider Demographics
NPI:1750710901
Name:HART, JULIE (PTA)
Entity type:Individual
Prefix:
First Name:JULIE
Middle Name:
Last Name:HART
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 1:6421 WAYNE ST
Mailing Address - Street 2:
Mailing Address - City:UNION
Mailing Address - State:IL
Mailing Address - Zip Code:60180-9792
Mailing Address - Country:US
Mailing Address - Phone:815-900-6987
Mailing Address - Fax:
Practice Address - Street 1:550 S MULFORD RD
Practice Address - Street 2:
Practice Address - City:ROCKFORD
Practice Address - State:IL
Practice Address - Zip Code:61108-2511
Practice Address - Country:US
Practice Address - Phone:815-399-4989
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-11-08
Last Update Date:2013-11-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL160.005910225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant