Provider Demographics
NPI:1932583424
Name:WOLLENWEBER, GINGER
Entity Type:Individual
Prefix:
First Name:GINGER
Middle Name:
Last Name:WOLLENWEBER
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 1:251 2ND AVE
Mailing Address - Street 2:
Mailing Address - City:MONTGOMERY
Mailing Address - State:IL
Mailing Address - Zip Code:60538-1531
Mailing Address - Country:US
Mailing Address - Phone:630-649-1313
Mailing Address - Fax:
Practice Address - Street 1:3703 W LAKE AVE
Practice Address - Street 2:200
Practice Address - City:GLENVIEW
Practice Address - State:IL
Practice Address - Zip Code:60026-1223
Practice Address - Country:US
Practice Address - Phone:847-998-1188
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-07-14
Last Update Date:2015-07-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL160004407225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant