Healthcare Provider Details

I. General information

NPI: 1639851058
Provider Name (Legal Business Name): BRANDON REGAN DPT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/04/2023
Last Update Date: 07/14/2026
Certification Date: 07/14/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6226 NORTHWEST HWY
CRYSTAL LAKE IL
60014-7933
US

IV. Provider business mailing address

PO BOX 735263
CHICAGO IL
60673-5263
US

V. Phone/Fax

Practice location:
  • Phone: 815-398-9491
  • Fax: 815-381-7498
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License NumberPTH11479
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: