Provider Demographics
NPI:1841229549
Name:VONDRUSKA, CAMILLE (PT)
Entity type:Individual
Prefix:
First Name:CAMILLE
Middle Name:
Last Name:VONDRUSKA
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:694 FOREST AVE
Mailing Address - Street 2:
Mailing Address - City:GLEN ELLYN
Mailing Address - State:IL
Mailing Address - Zip Code:60137-4121
Mailing Address - Country:US
Mailing Address - Phone:630-853-9467
Mailing Address - Fax:
Practice Address - Street 1:100 E WALTON ST
Practice Address - Street 2:SUITE 700
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60611-1448
Practice Address - Country:US
Practice Address - Phone:312-642-3963
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-03
Last Update Date:2017-04-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL070009255225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILP96755Medicare UPIN