Healthcare Provider Details

I. General information

NPI: 1649590043
Provider Name (Legal Business Name): LAURA JO ANN DE FALCO
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/08/2010
Last Update Date: 06/08/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

43 BANKVIEW DR
FRANKFORT IL
60423-1861
US

IV. Provider business mailing address

40 E JOLIET ST SUITE A
SCHERERVILLE IN
46375-2054
US

V. Phone/Fax

Practice location:
  • Phone: 815-469-6676
  • Fax: 815-469-1889
Mailing address:
  • Phone: 219-310-1032
  • Fax: 708-887-5501

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License Number056006307
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: