Provider Demographics
NPI:1649590043
Name:DE FALCO, LAURA JO ANN
Entity Type:Individual
Prefix:
First Name:LAURA JO
Middle Name:ANN
Last Name:DE FALCO
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:40 E JOLIET ST
Mailing Address - Street 2:SUITE A
Mailing Address - City:SCHERERVILLE
Mailing Address - State:IN
Mailing Address - Zip Code:46375-2054
Mailing Address - Country:US
Mailing Address - Phone:219-310-1032
Mailing Address - Fax:708-887-5501
Practice Address - Street 1:43 BANKVIEW DR
Practice Address - Street 2:
Practice Address - City:FRANKFORT
Practice Address - State:IL
Practice Address - Zip Code:60423-1861
Practice Address - Country:US
Practice Address - Phone:815-469-6676
Practice Address - Fax:815-469-1889
Is Sole Proprietor?:No
Enumeration Date:2010-06-08
Last Update Date:2010-06-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL056006307225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist