Provider Demographics
NPI:1407290448
Name:DECARLO, RICHARD BRENT (PT)
Entity Type:Individual
Prefix:
First Name:RICHARD
Middle Name:BRENT
Last Name:DECARLO
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 1:625 ENTERPRISE DR
Mailing Address - Street 2:
Mailing Address - City:OAK BROOK
Mailing Address - State:IL
Mailing Address - Zip Code:60523-8813
Mailing Address - Country:US
Mailing Address - Phone:630-575-6200
Mailing Address - Fax:
Practice Address - Street 1:1053 N MAIN ST
Practice Address - Street 2:SUITE 200
Practice Address - City:ELBURN
Practice Address - State:IL
Practice Address - Zip Code:60119-9118
Practice Address - Country:US
Practice Address - Phone:630-365-2400
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-04-22
Last Update Date:2017-06-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
070-010413225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist