MEDICARE: REGINA VANDEVELDE PT, DPT

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	225100000X	Physical Therapist	070015890	IL

General Provider Information

NPI Number	:	1891025375
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	REGINA VANDEVELDE PT, DPT

Provider Business Mailing Address
First Line	:	1206 E 9TH ST
Second Line	:	SUITE 160
City	:	LOCKPORT
State	:	IL
Zip	:	60441-2404
Country	:	US
Telephone Number	:	815-834-8700
Fax Number	:	815-838-1524

Provider Business Practice Location Address
First Line	:	1206 E 9TH ST
Second Line	:	SUITE 160
City	:	LOCKPORT
State	:	IL
Zip	:	60441-2404
Country	:	US
Telephone Number	:	815-834-8700
Fax Number	:	815-838-1524

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	01/06/2010
Last Update Date	:	05/01/2013

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