Provider Demographics
NPI:1659899128
Name:ABOUSSLEMAN, BRADY GEORGE (DPT, PT, AT, ATC)
Entity type:Individual
Prefix:
First Name:BRADY
Middle Name:GEORGE
Last Name:ABOUSSLEMAN
Suffix:
Gender:M
Credentials:DPT, PT, AT, ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1101 IROQUOIS AVE APT 2305
Mailing Address - Street 2:
Mailing Address - City:NAPERVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:60563-1427
Mailing Address - Country:US
Mailing Address - Phone:906-250-5630
Mailing Address - Fax:
Practice Address - Street 1:7 BLANCHARD CIR STE LLA
Practice Address - Street 2:
Practice Address - City:WHEATON
Practice Address - State:IL
Practice Address - Zip Code:60189-2049
Practice Address - Country:US
Practice Address - Phone:630-933-1500
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-09-05
Last Update Date:2024-06-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
2255A2300X
IL070.028262225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
No2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer