Basic Information
| Provider Information | |||||||||
| NPI: | 1912903394 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | WUEBBELS | ||||||||
| FirstName: | ANGELA | ||||||||
| MiddleName: | D | ||||||||
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| Credential: | PT | ||||||||
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| Mailing Information | |||||||||
| Address1: | 916 TALON DR | ||||||||
| Address2: | STE 102 | ||||||||
| City: | O FALLON | ||||||||
| State: | IL | ||||||||
| PostalCode: | 622691848 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6186288211 | ||||||||
| FaxNumber: | 6186280883 | ||||||||
| Practice Location | |||||||||
| Address1: | 12 WOLF CREEK DR | ||||||||
| Address2: | STE 200 | ||||||||
| City: | SWANSEA | ||||||||
| State: | IL | ||||||||
| PostalCode: | 622262343 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6182399910 | ||||||||
| FaxNumber: | 6182399795 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/22/2005 | ||||||||
| LastUpdateDate: | 01/08/2008 | ||||||||
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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 | IL | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
ID Information
| ID | Type | State | Issuer | Description | P00110675 | 01 | IL | MEDICARE RAILROAD | OTHER | 7894268 | 01 | IL | AETNA | OTHER | 08220357 | 01 | IL | BCBS GRP# | OTHER |