Provider Demographics
NPI:1891077988
Name:GERVAIS, AMY DANIELLE
Entity Type:Individual
Prefix:
First Name:AMY
Middle Name:DANIELLE
Last Name:GERVAIS
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 1:6 KNOLLWOOD DR
Mailing Address - Street 2:
Mailing Address - City:FLOSSMOOR
Mailing Address - State:IL
Mailing Address - Zip Code:60422-1928
Mailing Address - Country:US
Mailing Address - Phone:708-983-3942
Mailing Address - Fax:
Practice Address - Street 1:6 KNOLLWOOD DR
Practice Address - Street 2:
Practice Address - City:FLOSSMOOR
Practice Address - State:IL
Practice Address - Zip Code:60422-1928
Practice Address - Country:US
Practice Address - Phone:708-983-3942
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-09-14
Last Update Date:2011-09-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL056.009387225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist