Provider Demographics
NPI:1548268774
Name:PROFESSIONAL THERAPEUTIC GROUP, LLC
Entity type:Organization
Organization Name:PROFESSIONAL THERAPEUTIC GROUP, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR/OWNER
Authorized Official - Prefix:MRS
Authorized Official - First Name:LANA
Authorized Official - Middle Name:R
Authorized Official - Last Name:JOYNER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:618-998-9894
Mailing Address - Street 1:2907 WILLIAMSON COUNTY PKWY
Mailing Address - Street 2:
Mailing Address - City:MARION
Mailing Address - State:IL
Mailing Address - Zip Code:62959-5256
Mailing Address - Country:US
Mailing Address - Phone:618-998-9894
Mailing Address - Fax:618-998-9993
Practice Address - Street 1:2907 WILLIAMSON COUNTY PKWY
Practice Address - Street 2:
Practice Address - City:MARION
Practice Address - State:IL
Practice Address - Zip Code:62959-5256
Practice Address - Country:US
Practice Address - Phone:618-998-9894
Practice Address - Fax:618-998-9993
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-07-12
Last Update Date:2008-08-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty
No225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistGroup - Single Specialty
No235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language PathologistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL318540756001Medicaid
IL351786086001Medicaid
IL325688945001Medicaid
IL351786086001Medicaid