Provider Demographics
NPI:1235797341
Name:DE VALK, DEMOTRIS DWAYNE JR
Entity Type:Individual
Prefix:
First Name:DEMOTRIS
Middle Name:DWAYNE
Last Name:DE VALK
Suffix:JR
Gender:M
Credentials:
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 735044
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60673-5044
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:13250 WASHINGTON AVE
Practice Address - Street 2:
Practice Address - City:MOUNT PLEASANT
Practice Address - State:WI
Practice Address - Zip Code:53177-1516
Practice Address - Country:US
Practice Address - Phone:262-799-8330
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-06-04
Last Update Date:2023-11-02
Deactivation Date:2019-06-04
Deactivation Code:
Reactivation Date:2023-10-25
Provider Licenses
StateLicense IDTaxonomies
225400000X
WI16408225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
No225400000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRehabilitation Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
911-39026-02Other80840