Provider Demographics
NPI:1811268329
Name:VAN DERVEER, RICHARD MARK (LMT)
Entity type:Individual
Prefix:
First Name:RICHARD
Middle Name:MARK
Last Name:VAN DERVEER
Suffix:
Gender:M
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5506 OAKWOOD DR
Mailing Address - Street 2:
Mailing Address - City:OAKWOOD HILLS
Mailing Address - State:IL
Mailing Address - Zip Code:60013-1081
Mailing Address - Country:US
Mailing Address - Phone:224-440-3534
Mailing Address - Fax:
Practice Address - Street 1:5506 OAKWOOD DR
Practice Address - Street 2:
Practice Address - City:OAKWOOD HILLS
Practice Address - State:IL
Practice Address - Zip Code:60013-1081
Practice Address - Country:US
Practice Address - Phone:224-440-3534
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-01-16
Last Update Date:2012-01-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL227.005080225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist