Provider Demographics
NPI:1730356817
Name:ANZELMO, MARILYN
Entity type:Individual
Prefix:
First Name:MARILYN
Middle Name:
Last Name:ANZELMO
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 1:188 WICKHAM AVE
Mailing Address - Street 2:
Mailing Address - City:BLOOMINGDALE
Mailing Address - State:IL
Mailing Address - Zip Code:60108-3004
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1325 MANCHESTER RD
Practice Address - Street 2:
Practice Address - City:WHEATON
Practice Address - State:IL
Practice Address - Zip Code:60187-4760
Practice Address - Country:US
Practice Address - Phone:630-668-2500
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-05-08
Last Update Date:2008-05-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL070000695225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist