Provider Demographics
NPI:1013009182
Name:DERKS, AMY L (PT)
Entity Type:Individual
Prefix:
First Name:AMY
Middle Name:L
Last Name:DERKS
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:AMY
Other - Middle Name:L
Other - Last Name:BROWN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PT
Mailing Address - Street 1:790 REMINGTON BLVD
Mailing Address - Street 2:
Mailing Address - City:BOLINGBROOK
Mailing Address - State:IL
Mailing Address - Zip Code:60440-4909
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:4334 FOX VALLEY CENTER DR
Practice Address - Street 2:SUITE C
Practice Address - City:AURORA
Practice Address - State:IL
Practice Address - Zip Code:60504-7945
Practice Address - Country:US
Practice Address - Phone:630-236-7544
Practice Address - Fax:630-236-7574
Is Sole Proprietor?:No
Enumeration Date:2006-09-28
Last Update Date:2010-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL070014744225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILIL2993009Medicare PIN
ILK25321Medicare PIN