Provider Demographics
NPI:1487778791
Name:BRASS, DONNETTE ANITRA (PT)
Entity type:Individual
Prefix:MRS
First Name:DONNETTE
Middle Name:ANITRA
Last Name:BRASS
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:790 REMINGTON BLVD
Mailing Address - Street 2:
Mailing Address - City:BOLINGBROOK
Mailing Address - State:IL
Mailing Address - Zip Code:60440-4909
Mailing Address - Country:US
Mailing Address - Phone:630-296-2223
Mailing Address - Fax:
Practice Address - Street 1:1306 GEMINI CIR
Practice Address - Street 2:SUITE 3
Practice Address - City:OTTAWA
Practice Address - State:IL
Practice Address - Zip Code:61350-1694
Practice Address - Country:US
Practice Address - Phone:815-431-9980
Practice Address - Fax:815-431-9981
Is Sole Proprietor?:No
Enumeration Date:2007-03-19
Last Update Date:2011-05-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL070-013097225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILP00915429OtherMEDICARE RAILROAD
IL216860044Medicare PIN
IL202845160Medicare PIN