Basic Information
Provider Information
NPI: 1033559075
EntityType: 1
ReplacementNPI:  
OrganizationName:  
LastName: PFANZ
FirstName: BROOKE
MiddleName:  
NamePrefix:  
NameSuffix:  
Credential:  
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Mailing Information
Address1: 226 EAGLE DR
Address2:  
City: GREEN VALLEY
State: IL
PostalCode: 615349008
CountryCode: US
TelephoneNumber:  
FaxNumber:  
Practice Location
Address1: 3703 W LAKE AVE
Address2: SUITE 200
City: GLENVIEW
State: IL
PostalCode: 600261223
CountryCode: US
TelephoneNumber: 8479981188
FaxNumber:  
Other Information
ProviderEnumerationDate: 07/03/2013
LastUpdateDate: 07/03/2013
NPIDeactivationReasonCode:  
NPIDeactivationDate:  
NPIReactivationDate:  
ProviderGenderCode: F
AuthorizedOfficialLastName:  
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IsSoleProprietor: N
IsOrganizationSubpart:  
ParentOrganizationLBN:  
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AuthorizedOfficialNameSuffix:  
AuthorizedOfficialCredential:  

Taxonomy Information
TaxonomyLicenseStateSwitchTaxonomyGroupTaxonomyTypeTaxonomyClassSubSpecialty
225X00000X057.003171ILY Respiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist 

No ID Information.


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