Provider Demographics
NPI:1942026125
Name:PANTAZOPOULOS, CASEY
Entity type:Individual
Prefix:
First Name:CASEY
Middle Name:
Last Name:PANTAZOPOULOS
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 1:1032 S LA GRANGE RD STE 6
Mailing Address - Street 2:
Mailing Address - City:LA GRANGE
Mailing Address - State:IL
Mailing Address - Zip Code:60525-2881
Mailing Address - Country:US
Mailing Address - Phone:630-999-7223
Mailing Address - Fax:
Practice Address - Street 1:1032 S LA GRANGE RD STE 6
Practice Address - Street 2:
Practice Address - City:LA GRANGE
Practice Address - State:IL
Practice Address - Zip Code:60525-2881
Practice Address - Country:US
Practice Address - Phone:630-999-7223
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-12-03
Last Update Date:2024-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
171400000X
IL173C00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes173C00000XOther Service ProvidersReflexologist
No171400000XOther Service ProvidersHealth & Wellness Coach