Provider Demographics
NPI:1235916644
Name:BANUELOS, JOSHUA RAY (PT, DPT)
Entity Type:Individual
Prefix:
First Name:JOSHUA
Middle Name:RAY
Last Name:BANUELOS
Suffix:
Gender:M
Credentials:PT, DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2349 N DRAKE AVE APT 2
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60647-7721
Mailing Address - Country:US
Mailing Address - Phone:541-690-4595
Mailing Address - Fax:
Practice Address - Street 1:409 W HURON ST STE 300
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60654-3431
Practice Address - Country:US
Practice Address - Phone:312-604-2562
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-09-11
Last Update Date:2023-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL070027715225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist