Provider Demographics
NPI:1215154927
Name:GONZALES, MIA M (PT)
Entity type:Individual
Prefix:
First Name:MIA
Middle Name:M
Last Name:GONZALES
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:MIA
Other - Middle Name:G
Other - Last Name:MAGSOMBOL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PT
Mailing Address - Street 1:PO BOX 713260
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60677-1260
Mailing Address - Country:US
Mailing Address - Phone:630-469-9200
Mailing Address - Fax:
Practice Address - Street 1:854 ROOSEVELT RD UNIT E10
Practice Address - Street 2:
Practice Address - City:GLEN ELLYN
Practice Address - State:IL
Practice Address - Zip Code:60137-6057
Practice Address - Country:US
Practice Address - Phone:630-967-2000
Practice Address - Fax:708-995-1291
Is Sole Proprietor?:No
Enumeration Date:2007-04-20
Last Update Date:2023-05-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL070015338225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILDC7571OtherR.R. MEDICARE GROUP #
IL1619908OtherBCBS IL GROUP
ILCJ4383OtherR.R. MEDICARE GROUP #
IL1623066OtherBCBS PROVIDER #
IL567700OtherMEDICARE GROUP NUMBER
IL367885100OtherUS DEPT OF LABOR
IL567700OtherMEDICARE GROUP NUMBER
IL567770Medicare ID - Type UnspecifiedMEDICARE GROUP #
ILCJ4383OtherR.R. MEDICARE GROUP #