Provider Demographics
NPI:1770274300
Name:HURTADO-VAZQUEZ, SELENE
Entity type:Individual
Prefix:
First Name:SELENE
Middle Name:
Last Name:HURTADO-VAZQUEZ
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 1:30 N MICHIGAN AVE STE 1001
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60602-3502
Mailing Address - Country:US
Mailing Address - Phone:312-986-9833
Mailing Address - Fax:312-445-8623
Practice Address - Street 1:30 N MICHIGAN AVE STE 1001
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60602-3502
Practice Address - Country:US
Practice Address - Phone:312-986-9833
Practice Address - Fax:312-445-8623
Is Sole Proprietor?:No
Enumeration Date:2023-05-16
Last Update Date:2023-05-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL160007923225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant