Provider Demographics
NPI:1023683406
Name:WELLMAN, DEBORAH JO
Entity type:Individual
Prefix:
First Name:DEBORAH
Middle Name:JO
Last Name:WELLMAN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1029 W HARNETT ST
Mailing Address - Street 2:
Mailing Address - City:MASCOUTAH
Mailing Address - State:IL
Mailing Address - Zip Code:62258-1034
Mailing Address - Country:US
Mailing Address - Phone:618-406-3656
Mailing Address - Fax:
Practice Address - Street 1:3354 JEROME LN
Practice Address - Street 2:
Practice Address - City:CAHOKIA
Practice Address - State:IL
Practice Address - Zip Code:62206-2604
Practice Address - Country:US
Practice Address - Phone:618-337-9400
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-05-26
Last Update Date:2021-05-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL160.005466225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant