Provider Demographics
NPI:1891025375
Name:VANDEVELDE, REGINA (PT, DPT)
Entity Type:Individual
Prefix:
First Name:REGINA
Middle Name:
Last Name:VANDEVELDE
Suffix:
Gender:F
Credentials:PT, DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1206 E 9TH ST
Mailing Address - Street 2:SUITE 160
Mailing Address - City:LOCKPORT
Mailing Address - State:IL
Mailing Address - Zip Code:60441-2404
Mailing Address - Country:US
Mailing Address - Phone:815-834-8700
Mailing Address - Fax:815-838-1524
Practice Address - Street 1:1206 E 9TH ST
Practice Address - Street 2:SUITE 160
Practice Address - City:LOCKPORT
Practice Address - State:IL
Practice Address - Zip Code:60441-2404
Practice Address - Country:US
Practice Address - Phone:815-834-8700
Practice Address - Fax:815-838-1524
Is Sole Proprietor?:Yes
Enumeration Date:2010-01-06
Last Update Date:2013-05-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL070015890225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist