Provider Demographics
NPI:1659041192
Name:VALLE, VANESSA CAMERON
Entity Type:Individual
Prefix:
First Name:VANESSA
Middle Name:CAMERON
Last Name:VALLE
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 1:2827 N CAMBRIDGE AVE APT 306
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60657-6023
Mailing Address - Country:US
Mailing Address - Phone:650-477-9552
Mailing Address - Fax:
Practice Address - Street 1:1751 W DIVISION ST UNIT C-1E
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60622-4086
Practice Address - Country:US
Practice Address - Phone:773-278-9050
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-09-16
Last Update Date:2021-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL070.026239225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist