Healthcare Provider Details

I. General information

NPI: 1407022353
Provider Name (Legal Business Name): CANDICE LAURETA BRIONES P.T.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/01/2008
Last Update Date: 05/07/2022
Certification Date: 05/07/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1201 WYOMING AVE
JOLIET IL
60435-3718
US

IV. Provider business mailing address

2023 ENGLE RD
NAPERVILLE IL
60564-5386
US

V. Phone/Fax

Practice location:
  • Phone: 815-725-6631
  • Fax:
Mailing address:
  • Phone: 630-660-9266
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number070.013068
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: