Provider Demographics
NPI:1811258346
Name:MATA, JANIE LYN (PT)
Entity type:Individual
Prefix:
First Name:JANIE
Middle Name:LYN
Last Name:MATA
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:23528 N. EAST ROAD
Mailing Address - Street 2:
Mailing Address - City:LAKE ZURICH
Mailing Address - State:IL
Mailing Address - Zip Code:60047
Mailing Address - Country:US
Mailing Address - Phone:847-877-9836
Mailing Address - Fax:847-205-4645
Practice Address - Street 1:545 BELMONT LN
Practice Address - Street 2:
Practice Address - City:CAROL STREAM
Practice Address - State:IL
Practice Address - Zip Code:60188-2467
Practice Address - Country:US
Practice Address - Phone:630-510-1515
Practice Address - Fax:630-510-0633
Is Sole Proprietor?:No
Enumeration Date:2012-05-31
Last Update Date:2012-11-02
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
IL070.015076225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist