Provider Demographics
NPI:1215696893
Name:DANTA, BRIANNA (PTA)
Entity type:Individual
Prefix:MISS
First Name:BRIANNA
Middle Name:
Last Name:DANTA
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 1:17130 PRIME BLVD
Mailing Address - Street 2:
Mailing Address - City:LOCKPORT
Mailing Address - State:IL
Mailing Address - Zip Code:60441-1311
Mailing Address - Country:US
Mailing Address - Phone:708-518-3508
Mailing Address - Fax:
Practice Address - Street 1:183 N MAIN ST
Practice Address - Street 2:
Practice Address - City:MANTENO
Practice Address - State:IL
Practice Address - Zip Code:60950-1243
Practice Address - Country:US
Practice Address - Phone:815-261-0044
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-12-10
Last Update Date:2021-12-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL160.008751225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy AssistantGroup - Single Specialty