Healthcare Provider Details

I. General information

NPI: 1942531462
Provider Name (Legal Business Name): ROBERTA DEARTH
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/22/2010
Last Update Date: 01/22/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

25652 W COLLEEN CT
CHANNAHON IL
60410-8638
US

IV. Provider business mailing address

25652 W COLLEEN CT
CHANNAHON IL
60410-8638
US

V. Phone/Fax

Practice location:
  • Phone: 815-791-1510
  • Fax: 815-886-5983
Mailing address:
  • Phone: 815-791-1510
  • Fax: 815-886-5983

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225700000X
TaxonomyMassage Therapist
License Number227008582
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: