Provider Demographics
NPI:1598066862
Name:THOMAS, BERTINA (PTA)
Entity type:Individual
Prefix:MISS
First Name:BERTINA
Middle Name:
Last Name:THOMAS
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 1:15716 LINCOLN AVE
Mailing Address - Street 2:
Mailing Address - City:HARVEY
Mailing Address - State:IL
Mailing Address - Zip Code:60426-4136
Mailing Address - Country:US
Mailing Address - Phone:708-527-7064
Mailing Address - Fax:
Practice Address - Street 1:9826 S WESTERN AVE
Practice Address - Street 2:
Practice Address - City:EVERGREEN PARK
Practice Address - State:IL
Practice Address - Zip Code:60805-3200
Practice Address - Country:US
Practice Address - Phone:708-952-8220
Practice Address - Fax:708-423-5281
Is Sole Proprietor?:No
Enumeration Date:2010-11-03
Last Update Date:2010-11-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL160005044225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant