Provider Demographics
NPI:1639229180
Name:LOISELLE, MEVA (PT)
Entity Type:Individual
Prefix:
First Name:MEVA
Middle Name:
Last Name:LOISELLE
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:600 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:630-575-6250
Mailing Address - Fax:
Practice Address - Street 1:3 MEADOWVIEW CTR
Practice Address - Street 2:
Practice Address - City:KANKAKEE
Practice Address - State:IL
Practice Address - Zip Code:60901-2041
Practice Address - Country:US
Practice Address - Phone:815-932-7787
Practice Address - Fax:815-932-7895
Is Sole Proprietor?:No
Enumeration Date:2007-01-10
Last Update Date:2018-11-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL070-007936225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL070-007936OtherPT STATE LICENSE #
IL14663601Medicare ID - Type Unspecified