Provider Demographics
NPI:1942466438
Name:VANDEVELDE, BRAD W (PT)
Entity Type:Individual
Prefix:
First Name:BRAD
Middle Name:W
Last Name:VANDEVELDE
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:790 REMINGTON BLVD
Mailing Address - Street 2:
Mailing Address - City:BOLINGBROOK
Mailing Address - State:IL
Mailing Address - Zip Code:60440-4909
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:972 BROOK FOREST AVE
Practice Address - Street 2:
Practice Address - City:SHOREWOOD
Practice Address - State:IL
Practice Address - Zip Code:60404-8807
Practice Address - Country:US
Practice Address - Phone:815-439-4938
Practice Address - Fax:815-439-7816
Is Sole Proprietor?:No
Enumeration Date:2008-08-04
Last Update Date:2013-10-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL070-016543225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILP01019766OtherMEDICARE RAILROAD
IL202845156Medicare PIN
ILP01019766OtherMEDICARE RAILROAD