Basic Information
| Provider Information | |||||||||
| NPI: | 1700168689 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BARTUCCI | ||||||||
| FirstName: | CRYSTAL | ||||||||
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| Credential: | PTA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 14550 AVERS AVE | ||||||||
| Address2: | |||||||||
| City: | MIDLOTHIAN | ||||||||
| State: | IL | ||||||||
| PostalCode: | 604452812 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7087687165 | ||||||||
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| Practice Location | |||||||||
| Address1: | 11531 SWINFORD LN | ||||||||
| Address2: | |||||||||
| City: | MOKENA | ||||||||
| State: | IL | ||||||||
| PostalCode: | 604489274 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2192290322 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 09/15/2011 | ||||||||
| LastUpdateDate: | 09/16/2011 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225200000X | 160.005775 | IL | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapy Assistant |
No ID Information.