Healthcare Provider Details

I. General information

NPI: 1245543362
Provider Name (Legal Business Name): AMABELLE LEE BALOY DAVID RPT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/18/2010
Last Update Date: 07/18/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6501 S CASS AVE
WESTMONT IL
60559-3200
US

IV. Provider business mailing address

2320 PEBBLESTONE WAY
BOLINGBROOK IL
60490-5059
US

V. Phone/Fax

Practice location:
  • Phone: 630-960-2026
  • Fax:
Mailing address:
  • Phone: 815-677-0239
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number070017397
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: