Provider Demographics
NPI:1255397592
Name:DEVERELL, CRAIG W (ATC, CSCS)
Entity type:Individual
Prefix:MR
First Name:CRAIG
Middle Name:W
Last Name:DEVERELL
Suffix:
Gender:M
Credentials:ATC, CSCS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5452 N KRUSE RD
Mailing Address - Street 2:
Mailing Address - City:MT ZION
Mailing Address - State:IL
Mailing Address - Zip Code:62549-2723
Mailing Address - Country:US
Mailing Address - Phone:217-433-0123
Mailing Address - Fax:
Practice Address - Street 1:1900 E LAKE SHORE DR
Practice Address - Street 2:SUITE 150
Practice Address - City:DECATUR
Practice Address - State:IL
Practice Address - Zip Code:62521-3824
Practice Address - Country:US
Practice Address - Phone:217-428-6222
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-04-25
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL2255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer