Provider Demographics
NPI:1598219990
Name:PHAM, ANDY (DPT)
Entity Type:Individual
Prefix:
First Name:ANDY
Middle Name:
Last Name:PHAM
Suffix:
Gender:M
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:790 REMINGTON BLVD
Mailing Address - Street 2:
Mailing Address - City:BOLINGBROOK
Mailing Address - State:IL
Mailing Address - Zip Code:60440-4909
Mailing Address - Country:US
Mailing Address - Phone:630-296-2223
Mailing Address - Fax:
Practice Address - Street 1:84 WILLIMANSETT ST
Practice Address - Street 2:
Practice Address - City:SOUTH HADLEY
Practice Address - State:MA
Practice Address - Zip Code:01075-3062
Practice Address - Country:US
Practice Address - Phone:413-533-8501
Practice Address - Fax:413-533-8502
Is Sole Proprietor?:No
Enumeration Date:2016-08-15
Last Update Date:2017-05-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA22455225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist