Provider Demographics
NPI:1316686611
Name:POULOS, VALERIE NICOLE
Entity type:Individual
Prefix:
First Name:VALERIE
Middle Name:NICOLE
Last Name:POULOS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1732 KENNSINGTON LN
Mailing Address - Street 2:
Mailing Address - City:CRYSTAL LAKE
Mailing Address - State:IL
Mailing Address - Zip Code:60014-2047
Mailing Address - Country:US
Mailing Address - Phone:815-345-9034
Mailing Address - Fax:
Practice Address - Street 1:701 N KRAMER AVE
Practice Address - Street 2:
Practice Address - City:LOMBARD
Practice Address - State:IL
Practice Address - Zip Code:60148-1943
Practice Address - Country:US
Practice Address - Phone:630-651-2075
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-06-03
Last Update Date:2022-06-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes222Q00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersDevelopmental Therapist