=====================================================
General NPI Number Information
=====================================================
NPI Number | 1932672433
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | HOLLY ELIZABETH DEROO
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/07/2019
-----------------------------------------------------
Last Update Date | 01/07/2019
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1653 W CONGRESS PKWY
-----------------------------------------------------
City | CHICAGO
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60612-3833
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 312-942-5000
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 635 W BRIAR PL APT 4
-----------------------------------------------------
City | CHICAGO
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60657-7297
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 847-340-6796
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 225100000X
-----------------------------------------------------
Taxonomy Name | Physical Therapist
-----------------------------------------------------
License Number | 070.020984
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------