Basic Information
| Provider Information | |||||||||
| NPI: | 1568592822 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | PRINCE | ||||||||
| FirstName: | AEBA | ||||||||
| MiddleName: | T | ||||||||
| NamePrefix: | MRS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | PT | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | THANKARAJ | ||||||||
| OtherFirstName: | AEBA | ||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | MRS. | ||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | 5 | ||||||||
| Mailing Information | |||||||||
| Address1: | 600 OAKMONT LN STE 600C | ||||||||
| Address2: | |||||||||
| City: | WESTMONT | ||||||||
| State: | IL | ||||||||
| PostalCode: | 605595548 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6305756200 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 231 W MAIN ST | ||||||||
| Address2: | SUITE 101 | ||||||||
| City: | CARPENTERSVILLE | ||||||||
| State: | IL | ||||||||
| PostalCode: | 60110 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8474281515 | ||||||||
| FaxNumber: | 8474280024 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/06/2007 | ||||||||
| LastUpdateDate: | 04/14/2022 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 04/14/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | 070.013747 | IL | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
ID Information
| ID | Type | State | Issuer | Description | 070.013747 | 01 | IL | STATE OF ILLINOIS LICENSE | OTHER |