Healthcare Provider Details

I. General information

NPI: 1063392298
Provider Name (Legal Business Name): AVARY LAUREN BIELEMA DPT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/08/2025
Last Update Date: 09/08/2025
Certification Date: 09/07/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1103 S STATE ST STE 300
CHICAGO IL
60605-2775
US

IV. Provider business mailing address

504 MEADOW LN
MORRISON IL
61270-3054
US

V. Phone/Fax

Practice location:
  • Phone: 312-877-5101
  • Fax:
Mailing address:
  • Phone: 815-499-8718
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number070029481
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: