Basic Information
| Provider Information | |||||||||
| NPI: | 1639229180 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | LOISELLE | ||||||||
| FirstName: | MEVA | ||||||||
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| Credential: | PT | ||||||||
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| Mailing Information | |||||||||
| Address1: | 600 OAKMONT LN STE 600C | ||||||||
| Address2: | |||||||||
| City: | WESTMONT | ||||||||
| State: | IL | ||||||||
| PostalCode: | 605595548 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6305756250 | ||||||||
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| Practice Location | |||||||||
| Address1: | 3 MEADOWVIEW CTR | ||||||||
| Address2: | |||||||||
| City: | KANKAKEE | ||||||||
| State: | IL | ||||||||
| PostalCode: | 609012041 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8159327787 | ||||||||
| FaxNumber: | 8159327895 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/10/2007 | ||||||||
| LastUpdateDate: | 11/12/2018 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | 070-007936 | IL | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
ID Information
| ID | Type | State | Issuer | Description | 070-007936 | 01 | IL | PT STATE LICENSE # | OTHER |