Provider Demographics
NPI:1780362483
Name:LITTLE, DALVIN D
Entity type:Individual
Prefix:
First Name:DALVIN
Middle Name:D
Last Name:LITTLE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:604 W WATER ST
Mailing Address - Street 2:
Mailing Address - City:WAUKEGAN
Mailing Address - State:IL
Mailing Address - Zip Code:60085-5431
Mailing Address - Country:US
Mailing Address - Phone:847-406-7530
Mailing Address - Fax:
Practice Address - Street 1:604 W WATER ST
Practice Address - Street 2:
Practice Address - City:WAUKEGAN
Practice Address - State:IL
Practice Address - Zip Code:60085-5431
Practice Address - Country:US
Practice Address - Phone:847-406-7530
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-07-11
Last Update Date:2023-07-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL001249644012251E1300X, 225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2251E1300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistElectrophysiology, Clinical
No225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL34016496101LMedicaid