Provider Demographics
NPI:1194400143
Name:FALLOWS, CHARLENE JOY
Entity type:Individual
Prefix:
First Name:CHARLENE
Middle Name:JOY
Last Name:FALLOWS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:955 SUTTON DR
Mailing Address - Street 2:
Mailing Address - City:NORTHBROOK
Mailing Address - State:IL
Mailing Address - Zip Code:60062-3017
Mailing Address - Country:US
Mailing Address - Phone:847-338-2576
Mailing Address - Fax:
Practice Address - Street 1:3300 MILWAUKEE AVE
Practice Address - Street 2:
Practice Address - City:NORTHBROOK
Practice Address - State:IL
Practice Address - Zip Code:60062-7126
Practice Address - Country:US
Practice Address - Phone:847-795-9700
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-06-19
Last Update Date:2023-06-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL100000886225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant