Provider Demographics
NPI:1306196753
Name:FENSHOLT, MEG ANNE (PTA)
Entity type:Individual
Prefix:
First Name:MEG
Middle Name:ANNE
Last Name:FENSHOLT
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 1:220 W JEFFERSON AVE
Mailing Address - Street 2:
Mailing Address - City:WHEATON
Mailing Address - State:IL
Mailing Address - Zip Code:60187-4111
Mailing Address - Country:US
Mailing Address - Phone:630-690-3315
Mailing Address - Fax:
Practice Address - Street 1:220 W JEFFERSON AVE
Practice Address - Street 2:
Practice Address - City:WHEATON
Practice Address - State:IL
Practice Address - Zip Code:60187-4111
Practice Address - Country:US
Practice Address - Phone:630-690-3315
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-09-13
Last Update Date:2012-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL160.005752225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL2207064117Medicare NSC