Provider Demographics
NPI:1699100354
Name:SIMON LAPORTE, PAMELA JEAN (PT)
Entity type:Individual
Prefix:MRS
First Name:PAMELA
Middle Name:JEAN
Last Name:SIMON LAPORTE
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:19534 SCARTH LN
Mailing Address - Street 2:
Mailing Address - City:MOKENA
Mailing Address - State:IL
Mailing Address - Zip Code:60448-1764
Mailing Address - Country:US
Mailing Address - Phone:815-263-9335
Mailing Address - Fax:
Practice Address - Street 1:14901 S. FOUNDERS CROSSING
Practice Address - Street 2:
Practice Address - City:HOMER GLEN
Practice Address - State:IL
Practice Address - Zip Code:60491-6712
Practice Address - Country:US
Practice Address - Phone:708-301-3571
Practice Address - Fax:708-301-4450
Is Sole Proprietor?:No
Enumeration Date:2013-09-12
Last Update Date:2013-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL070.016437225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist