Provider Demographics
NPI:1770237794
Name:SALAZAR, PAVIA (PTA)
Entity type:Individual
Prefix:
First Name:PAVIA
Middle Name:
Last Name:SALAZAR
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 1:1340 KINGSBURY DR UNIT 3
Mailing Address - Street 2:
Mailing Address - City:HANOVER PARK
Mailing Address - State:IL
Mailing Address - Zip Code:60133-7281
Mailing Address - Country:US
Mailing Address - Phone:630-823-1469
Mailing Address - Fax:
Practice Address - Street 1:110 W SCHAUMBURG RD
Practice Address - Street 2:
Practice Address - City:STREAMWOOD
Practice Address - State:IL
Practice Address - Zip Code:60107-1459
Practice Address - Country:US
Practice Address - Phone:630-372-4114
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-02-08
Last Update Date:2022-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL160.006113225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL160.006113OtherPHYSICAL THERAPY