Healthcare Provider Details

I. General information

NPI: 1376059774
Provider Name (Legal Business Name): CASEY JEAN DUVAL ATC, LAT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/20/2017
Last Update Date: 12/20/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2601 BUNKER HILL DR
ALGONQUIN IL
60102-9780
US

IV. Provider business mailing address

122 LAKEWOOD DR
OAKWOOD HILLS IL
60013-1122
US

V. Phone/Fax

Practice location:
  • Phone: 847-532-6153
  • Fax:
Mailing address:
  • Phone: 312-479-8689
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number096003994
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: