Provider Demographics
NPI:1932362035
Name:GURDIEL, IMELDA CARMELA BUENO (PHYSICAL THERAPIST)
Entity Type:Individual
Prefix:
First Name:IMELDA CARMELA
Middle Name:BUENO
Last Name:GURDIEL
Suffix:
Gender:F
Credentials:PHYSICAL THERAPIST
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:201 W HAMPTON DR
Mailing Address - Street 2:
Mailing Address - City:ROUND LAKE
Mailing Address - State:IL
Mailing Address - Zip Code:60073-5652
Mailing Address - Country:US
Mailing Address - Phone:847-740-5997
Mailing Address - Fax:
Practice Address - Street 1:201 W HAMPTON DR
Practice Address - Street 2:
Practice Address - City:ROUND LAKE
Practice Address - State:IL
Practice Address - Zip Code:60073-5652
Practice Address - Country:US
Practice Address - Phone:847-740-5997
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-07-08
Last Update Date:2008-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL070.013837225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist