Basic Information
| Provider Information | |||||||||
| NPI: | 1023683406 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | WELLMAN | ||||||||
| FirstName: | DEBORAH | ||||||||
| MiddleName: | JO | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1029 W HARNETT ST | ||||||||
| Address2: | |||||||||
| City: | MASCOUTAH | ||||||||
| State: | IL | ||||||||
| PostalCode: | 622581034 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6184063656 | ||||||||
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| Practice Location | |||||||||
| Address1: | 3354 JEROME LN | ||||||||
| Address2: | |||||||||
| City: | CAHOKIA | ||||||||
| State: | IL | ||||||||
| PostalCode: | 622062604 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6183379400 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 05/26/2021 | ||||||||
| LastUpdateDate: | 05/26/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 05/26/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225200000X | 160.005466 | IL | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapy Assistant |
No ID Information.