Provider Demographics
NPI:1881567212
Name:SUICO, EARL JUSTIN (PTA)
Entity type:Individual
Prefix:
First Name:EARL
Middle Name:JUSTIN
Last Name:SUICO
Suffix:
Gender:M
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1461 W SUMMERDALE AVE APT 1B
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60640-2149
Mailing Address - Country:US
Mailing Address - Phone:331-645-0936
Mailing Address - Fax:
Practice Address - Street 1:901 BIESTERFIELD RD STE 308
Practice Address - Street 2:
Practice Address - City:ELK GROVE VILLAGE
Practice Address - State:IL
Practice Address - Zip Code:60007-7324
Practice Address - Country:US
Practice Address - Phone:847-437-9889
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-09-23
Last Update Date:2025-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL160.006852225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant