Provider Demographics
NPI:1215257324
Name:ZIMMERMAN, MEGAN MARIE (PTA)
Entity type:Individual
Prefix:
First Name:MEGAN
Middle Name:MARIE
Last Name:ZIMMERMAN
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 1:3550 COLLEGE AVE
Mailing Address - Street 2:SUITE A
Mailing Address - City:ALTON
Mailing Address - State:IL
Mailing Address - Zip Code:62002-5008
Mailing Address - Country:US
Mailing Address - Phone:618-465-6566
Mailing Address - Fax:618-465-6573
Practice Address - Street 1:3550 COLLEGE AVE
Practice Address - Street 2:SUITE A
Practice Address - City:ALTON
Practice Address - State:IL
Practice Address - Zip Code:62002-5008
Practice Address - Country:US
Practice Address - Phone:618-465-6566
Practice Address - Fax:618-465-6573
Is Sole Proprietor?:Yes
Enumeration Date:2010-06-11
Last Update Date:2010-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL160.004495225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant