Provider Demographics
NPI:1902244726
Name:FONTANILLA, MARIA CRISELDA (PT)
Entity Type:Individual
Prefix:
First Name:MARIA CRISELDA
Middle Name:
Last Name:FONTANILLA
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5440 N CUMBERLAND AVE STE A101
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60656-4701
Mailing Address - Country:US
Mailing Address - Phone:773-444-0400
Mailing Address - Fax:
Practice Address - Street 1:5440 N CUMBERLAND AVE STE A101
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60656-4701
Practice Address - Country:US
Practice Address - Phone:773-444-0400
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-06-14
Last Update Date:2013-06-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL070.019729225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist