Provider Demographics
NPI:1194173690
Name:GREGG, WILLA (PTA)
Entity type:Individual
Prefix:
First Name:WILLA
Middle Name:
Last Name:GREGG
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1457 N LINDER AVE
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60651-1233
Mailing Address - Country:US
Mailing Address - Phone:312-203-9616
Mailing Address - Fax:773-237-0709
Practice Address - Street 1:1457 N LINDER AVE
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60651-1233
Practice Address - Country:US
Practice Address - Phone:312-203-9616
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-05-25
Last Update Date:2016-05-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL160.000756172V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker