Healthcare Provider Details

I. General information

NPI: 1205181542
Provider Name (Legal Business Name): AMANDA VANDERVELDE PT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/23/2012
Last Update Date: 07/23/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4440 W 95TH ST
OAK LAWN IL
60453-2600
US

IV. Provider business mailing address

17725 66TH AVE
TINLEY PARK IL
60477-4128
US

V. Phone/Fax

Practice location:
  • Phone: 708-684-5425
  • Fax:
Mailing address:
  • Phone: 708-674-1659
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: