Provider Demographics
NPI:1346649910
Name:CANDREVA, SHERLEEN (LMT)
Entity type:Individual
Prefix:
First Name:SHERLEEN
Middle Name:
Last Name:CANDREVA
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1275 MEADOW PATH
Mailing Address - Street 2:
Mailing Address - City:MANTENO
Mailing Address - State:IL
Mailing Address - Zip Code:60950-3743
Mailing Address - Country:US
Mailing Address - Phone:708-790-0492
Mailing Address - Fax:708-534-5519
Practice Address - Street 1:5601 W MONEE MANHATTAN RD
Practice Address - Street 2:SUITE 100
Practice Address - City:MONEE
Practice Address - State:IL
Practice Address - Zip Code:60449-8862
Practice Address - Country:US
Practice Address - Phone:708-534-5248
Practice Address - Fax:708-534-5519
Is Sole Proprietor?:No
Enumeration Date:2014-08-19
Last Update Date:2014-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL227.007617225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist