Provider Demographics
NPI:1811132764
Name:ILLICH, MARION HUTCHINSON (PT)
Entity type:Individual
Prefix:MRS
First Name:MARION
Middle Name:HUTCHINSON
Last Name:ILLICH
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:65 SCUDDER PL
Mailing Address - Street 2:
Mailing Address - City:NORTHPORT
Mailing Address - State:NY
Mailing Address - Zip Code:11768-3026
Mailing Address - Country:US
Mailing Address - Phone:631-754-6791
Mailing Address - Fax:
Practice Address - Street 1:65 SCUDDER PL
Practice Address - Street 2:
Practice Address - City:NORTHPORT
Practice Address - State:NY
Practice Address - Zip Code:11768-3026
Practice Address - Country:US
Practice Address - Phone:631-754-6791
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-12-06
Last Update Date:2008-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY003909261QP2000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy