Provider Demographics
NPI:1255424149
Name:STURGEON, THERESA BASILO (PT)
Entity type:Individual
Prefix:
First Name:THERESA
Middle Name:BASILO
Last Name:STURGEON
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:THERESA
Other - Middle Name:M
Other - Last Name:BASILO
Other - Suffix:
Other - Last Name Type:Former Name
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 1:218 N BOLINGBROOK DR
Practice Address - Street 2:
Practice Address - City:BOLINGBROOK
Practice Address - State:IL
Practice Address - Zip Code:60440-2386
Practice Address - Country:US
Practice Address - Phone:630-972-1541
Practice Address - Fax:630-972-1571
Is Sole Proprietor?:No
Enumeration Date:2006-10-02
Last Update Date:2014-02-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL070015255225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILP00898812OtherMEDICARE RAILROAD
ILP00931560OtherMEDICARE RAILROAD
ILP00931560OtherMEDICARE RAILROAD
IL202845163Medicare PIN