Healthcare Provider Details

I. General information

NPI: 1104733575
Provider Name (Legal Business Name): BREANNA ADAMS ATC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/24/2026
Last Update Date: 08/24/2026
Certification Date: 08/24/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

285 E GRAND AVE
FOX LAKE IL
60020-1657
US

IV. Provider business mailing address

217 STAFFORD DR
MUNDELEIN IL
60060-2071
US

V. Phone/Fax

Practice location:
  • Phone: 847-973-3113
  • Fax: 847-587-1768
Mailing address:
  • Phone: 847-973-3113
  • Fax: 847-587-1768

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number096005623
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: