Provider Demographics
NPI:1245993278
Name:SONENTHAL, MALLORY (PT, DPT)
Entity type:Individual
Prefix:
First Name:MALLORY
Middle Name:
Last Name:SONENTHAL
Suffix:
Gender:F
Credentials:PT, DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1630 RAVINE LN
Mailing Address - Street 2:
Mailing Address - City:HIGHLAND PARK
Mailing Address - State:IL
Mailing Address - Zip Code:60035-3346
Mailing Address - Country:US
Mailing Address - Phone:847-266-7531
Mailing Address - Fax:
Practice Address - Street 1:710 S PAULINA ST
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60612-3808
Practice Address - Country:US
Practice Address - Phone:312-942-2791
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-10-17
Last Update Date:2021-10-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL070.025874225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist