Provider Demographics
NPI:1396093142
Name:GREENWELL, LUCAS J (DPT)
Entity type:Individual
Prefix:
First Name:LUCAS
Middle Name:J
Last Name:GREENWELL
Suffix:
Gender:M
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:20 E CHICAGO AVE
Mailing Address - Street 2:
Mailing Address - City:WESTMONT
Mailing Address - State:IL
Mailing Address - Zip Code:60559-1738
Mailing Address - Country:US
Mailing Address - Phone:331-253-2280
Mailing Address - Fax:833-506-3220
Practice Address - Street 1:20 E CHICAGO AVE
Practice Address - Street 2:
Practice Address - City:WESTMONT
Practice Address - State:IL
Practice Address - Zip Code:60559
Practice Address - Country:US
Practice Address - Phone:331-253-2280
Practice Address - Fax:833-506-3220
Is Sole Proprietor?:No
Enumeration Date:2012-08-28
Last Update Date:2019-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL070-019458225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist