Provider Demographics
NPI:1043783723
Name:MCGREGOR, CANDI L (LPTA)
Entity type:Individual
Prefix:
First Name:CANDI
Middle Name:L
Last Name:MCGREGOR
Suffix:
Gender:F
Credentials:LPTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1291 W LAKE ST APT 204
Mailing Address - Street 2:
Mailing Address - City:ADDISON
Mailing Address - State:IL
Mailing Address - Zip Code:60101-1186
Mailing Address - Country:US
Mailing Address - Phone:715-851-0888
Mailing Address - Fax:
Practice Address - Street 1:1082 SIBLEY BLVD
Practice Address - Street 2:
Practice Address - City:CALUMET CITY
Practice Address - State:IL
Practice Address - Zip Code:60409-2413
Practice Address - Country:US
Practice Address - Phone:708-203-0343
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-01-06
Last Update Date:2019-01-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL160.007093225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant