Provider Demographics
NPI:1407290448
Name:DECARLO, RICHARD B (PT)
Entity type:Individual
Prefix:
First Name:RICHARD
Middle Name:B
Last Name:DECARLO
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:RICHARD
Other - Middle Name:BETH
Other - Last Name:DE CARLO
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:PT
Mailing Address - Street 1:2122 YORK RD STE 300
Mailing Address - Street 2:
Mailing Address - City:OAK BROOK
Mailing Address - State:IL
Mailing Address - Zip Code:60523-1925
Mailing Address - Country:US
Mailing Address - Phone:630-575-1980
Mailing Address - Fax:630-928-5080
Practice Address - Street 1:1053 N MAIN ST STE 200
Practice Address - Street 2:
Practice Address - City:ELBURN
Practice Address - State:IL
Practice Address - Zip Code:60119-9118
Practice Address - Country:US
Practice Address - Phone:630-365-2400
Practice Address - Fax:630-365-2401
Is Sole Proprietor?:No
Enumeration Date:2013-04-22
Last Update Date:2024-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL070-010413225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist