Provider Demographics
NPI:1790900686
Name:GENEREAU, ANGEL V (LMT)
Entity Type:Individual
Prefix:MS
First Name:ANGEL
Middle Name:V
Last Name:GENEREAU
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7273 FLAGG CREEK DR
Mailing Address - Street 2:
Mailing Address - City:LA GRANGE
Mailing Address - State:IL
Mailing Address - Zip Code:60525-5307
Mailing Address - Country:US
Mailing Address - Phone:312-953-1424
Mailing Address - Fax:866-483-0652
Practice Address - Street 1:7273 FLAGG CREEK DR
Practice Address - Street 2:
Practice Address - City:LA GRANGE
Practice Address - State:IL
Practice Address - Zip Code:60525-5307
Practice Address - Country:US
Practice Address - Phone:312-953-1424
Practice Address - Fax:866-483-0652
Is Sole Proprietor?:No
Enumeration Date:2007-04-16
Last Update Date:2009-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL227004283172M00000X, 225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist
No172M00000XOther Service ProvidersMechanotherapist