Provider Demographics
NPI:1447809710
Name:MCDONALD, GINA LIN (LAT, ATC)
Entity type:Individual
Prefix:
First Name:GINA
Middle Name:LIN
Last Name:MCDONALD
Suffix:
Gender:F
Credentials:LAT, ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13132 W CREEKSIDE DR
Mailing Address - Street 2:
Mailing Address - City:HOMER GLEN
Mailing Address - State:IL
Mailing Address - Zip Code:60491-8105
Mailing Address - Country:US
Mailing Address - Phone:708-822-4462
Mailing Address - Fax:
Practice Address - Street 1:3551 HIGHLAND AVE
Practice Address - Street 2:
Practice Address - City:DOWNERS GROVE
Practice Address - State:IL
Practice Address - Zip Code:60515-2100
Practice Address - Country:US
Practice Address - Phone:630-275-2640
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-09-09
Last Update Date:2019-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL0960030622255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL096003062OtherILLINOIS DEPARTMENT OF FINANCIAL AND PROFESSIONAL REGULATION