Provider Demographics
NPI:1356394068
Name:SOUTHWORTH, THERESE R (PT)
Entity type:Individual
Prefix:
First Name:THERESE
Middle Name:R
Last Name:SOUTHWORTH
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:THERESE
Other - Middle Name:R
Other - Last Name:BREHMER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PT
Mailing Address - Street 1:205 W WACKER DR
Mailing Address - Street 2:SUITE105
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60606-1216
Mailing Address - Country:US
Mailing Address - Phone:312-640-0329
Mailing Address - Fax:
Practice Address - Street 1:1925 N GARY AVE
Practice Address - Street 2:
Practice Address - City:WHEATON
Practice Address - State:IL
Practice Address - Zip Code:60187-3056
Practice Address - Country:US
Practice Address - Phone:630-653-6336
Practice Address - Fax:630-653-6446
Is Sole Proprietor?:No
Enumeration Date:2006-05-17
Last Update Date:2014-03-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL070-004371225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILL99507Medicare PIN