Provider Demographics
NPI:1073837761
Name:SPEVAK, THOMAS (PT)
Entity Type:Individual
Prefix:
First Name:THOMAS
Middle Name:
Last Name:SPEVAK
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1329
Mailing Address - Street 2:
Mailing Address - City:BLOOMINGTON
Mailing Address - State:IN
Mailing Address - Zip Code:47402-1329
Mailing Address - Country:US
Mailing Address - Phone:812-353-3087
Mailing Address - Fax:812-353-5859
Practice Address - Street 1:1375 N WELLNESS WAY
Practice Address - Street 2:
Practice Address - City:BLOOMINGTON
Practice Address - State:IN
Practice Address - Zip Code:47404-9786
Practice Address - Country:US
Practice Address - Phone:812-676-4111
Practice Address - Fax:812-676-4110
Is Sole Proprietor?:No
Enumeration Date:2010-03-24
Last Update Date:2013-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN05002211A225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist