Provider Demographics
NPI:1871266429
Name:VALDEZ, AVIANA LYS
Entity Type:Individual
Prefix:
First Name:AVIANA
Middle Name:LYS
Last Name:VALDEZ
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 1:7421 MADISON ST
Mailing Address - Street 2:
Mailing Address - City:FOREST PARK
Mailing Address - State:IL
Mailing Address - Zip Code:60130-1575
Mailing Address - Country:US
Mailing Address - Phone:847-909-1490
Mailing Address - Fax:
Practice Address - Street 1:7421 MADISON ST
Practice Address - Street 2:
Practice Address - City:FOREST PARK
Practice Address - State:IL
Practice Address - Zip Code:60130-1575
Practice Address - Country:US
Practice Address - Phone:847-909-1490
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-07-29
Last Update Date:2021-07-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL056014265225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist