Provider Demographics
NPI:1497094684
Name:FOREMAN, AVERY K (PT)
Entity Type:Individual
Prefix:
First Name:AVERY
Middle Name:K
Last Name:FOREMAN
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:AVERY
Other - Middle Name:K
Other - Last Name:GRIFFIN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PT
Mailing Address - Street 1:600 OAKMONT LN STE 600C
Mailing Address - Street 2:
Mailing Address - City:WESTMONT
Mailing Address - State:IL
Mailing Address - Zip Code:60559-5548
Mailing Address - Country:US
Mailing Address - Phone:630-575-1940
Mailing Address - Fax:
Practice Address - Street 1:1044 SAGAMORE PKWY W
Practice Address - Street 2:UNIT A
Practice Address - City:WEST LAFAYETTE
Practice Address - State:IN
Practice Address - Zip Code:47906-1446
Practice Address - Country:US
Practice Address - Phone:765-250-4445
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-02-07
Last Update Date:2019-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DC225100000X
IN05011915A225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist