Provider Demographics
NPI:1558779876
Name:VALENZUELA, KENNETH-ALBERT FABABAER (PT)
Entity Type:Individual
Prefix:MR
First Name:KENNETH-ALBERT
Middle Name:FABABAER
Last Name:VALENZUELA
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 1:7440 HARRISON ST APT 2
Mailing Address - Street 2:
Mailing Address - City:FOREST PARK
Mailing Address - State:IL
Mailing Address - Zip Code:60130-2085
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:7440 HARRISON ST APT 2
Practice Address - Street 2:
Practice Address - City:FOREST PARK
Practice Address - State:IL
Practice Address - Zip Code:60130-2085
Practice Address - Country:US
Practice Address - Phone:708-790-9577
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-07-30
Last Update Date:2014-07-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL070020735225100000X
DEJ1-0003168225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist