Provider Demographics
NPI:1770128746
Name:EVANGELISTA, JONALD BOYLES (DPT)
Entity type:Individual
Prefix:
First Name:JONALD
Middle Name:BOYLES
Last Name:EVANGELISTA
Suffix:
Gender:M
Credentials:DPT
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:866-370-8206
Mailing Address - Fax:
Practice Address - Street 1:3157 FAIRLANE DR
Practice Address - Street 2:
Practice Address - City:ALLEN PARK
Practice Address - State:MI
Practice Address - Zip Code:48101-2866
Practice Address - Country:US
Practice Address - Phone:313-827-0099
Practice Address - Fax:313-749-0480
Is Sole Proprietor?:Yes
Enumeration Date:2019-11-13
Last Update Date:2023-10-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY032653225100000X
NV4240225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist