MEDICARE: EVANGELINE DE LEON 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	2305214667	VA

General Provider Information

NPI Number	:	1942956263
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	EVANGELINE DE LEON PT, DPT

Provider Business Mailing Address
First Line	:	790 REMINGTON BLVD
Second Line	:
City	:	BOLINGBROOK
State	:	IL
Zip	:	60440-4909
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	2441 N HARRISON ST STE 2443
Second Line	:
City	:	ARLINGTON
State	:	VA
Zip	:	22207-1611
Country	:	US
Telephone Number	:	571-533-3686
Fax Number	:	571-534-4800

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

Provider Enumeration Date	:	02/24/2022
Last Update Date	:	05/20/2024

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