Provider Demographics
NPI:1053404368
Name:LEISE, MARGARET L (PT)
Entity type:Individual
Prefix:
First Name:MARGARET
Middle Name:L
Last Name:LEISE
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:MARGARET
Other - Middle Name:L
Other - Last Name:BASDEN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PT
Mailing Address - Street 1:790 REMINGTON BLVD
Mailing Address - Street 2:
Mailing Address - City:BOLINGBROOK
Mailing Address - State:IL
Mailing Address - Zip Code:60440-4909
Mailing Address - Country:US
Mailing Address - Phone:630-296-2223
Mailing Address - Fax:
Practice Address - Street 1:16651 HARLEM AVE
Practice Address - Street 2:
Practice Address - City:TINLEY PARK
Practice Address - State:IL
Practice Address - Zip Code:60477-2581
Practice Address - Country:US
Practice Address - Phone:708-444-2838
Practice Address - Fax:708-444-3031
Is Sole Proprietor?:No
Enumeration Date:2006-10-02
Last Update Date:2011-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL070012199225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILP00931599OtherMEDICARE RAILROAD
ILP00852545OtherMEDICARE RR
IL202845062Medicare PIN
ILK26796Medicare ID - Type UnspecifiedMEDICARE MEMBER NUMBER
IL214692013Medicare PIN