Provider Demographics
NPI:1518018399
Name:AREVALO, AMANDA (PT, MS, PCS)
Entity Type:Individual
Prefix:
First Name:AMANDA
Middle Name:
Last Name:AREVALO
Suffix:
Gender:F
Credentials:PT, MS, PCS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6915 30TH PL
Mailing Address - Street 2:
Mailing Address - City:BERWYN
Mailing Address - State:IL
Mailing Address - Zip Code:60402-2957
Mailing Address - Country:US
Mailing Address - Phone:708-602-1581
Mailing Address - Fax:708-484-8841
Practice Address - Street 1:6915 30TH PL
Practice Address - Street 2:
Practice Address - City:BERWYN
Practice Address - State:IL
Practice Address - Zip Code:60402-2957
Practice Address - Country:US
Practice Address - Phone:708-602-1581
Practice Address - Fax:708-484-8841
Is Sole Proprietor?:No
Enumeration Date:2007-01-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL2251P0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2251P0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL1634441OtherBLUE CROSS BLUE SHIELD