Basic Information
| Provider Information | |||||||||
| NPI: | 1740506047 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | PIAZZA | ||||||||
| FirstName: | ASHLEY | ||||||||
| MiddleName: | E | ||||||||
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| Credential: | PT | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | BOON | ||||||||
| OtherFirstName: | ASHLEY | ||||||||
| OtherMiddleName: | E | ||||||||
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| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 790 REMINGTON BLVD | ||||||||
| Address2: | |||||||||
| City: | BOLINGBROOK | ||||||||
| State: | IL | ||||||||
| PostalCode: | 604404909 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6302962223 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 10860 HIGHLAND RD | ||||||||
| Address2: | |||||||||
| City: | HARTLAND | ||||||||
| State: | MI | ||||||||
| PostalCode: | 483532629 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8106321000 | ||||||||
| FaxNumber: | 8106321001 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/12/2010 | ||||||||
| LastUpdateDate: | 07/16/2014 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | 5501016544 | MI | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist | 225100000X | 070-017714 | IL | N | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
ID Information
| ID | Type | State | Issuer | Description | P01048511 | 01 | IL | MEDICARE RAILROAD | OTHER |