Provider Demographics
NPI:1427639400
Name:PATRICK, BRYLENE LAVELLE
Entity type:Individual
Prefix:
First Name:BRYLENE
Middle Name:LAVELLE
Last Name:PATRICK
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 1:15301 KNOX AVE APT 4
Mailing Address - Street 2:
Mailing Address - City:OAK FOREST
Mailing Address - State:IL
Mailing Address - Zip Code:60452-2542
Mailing Address - Country:US
Mailing Address - Phone:210-780-0854
Mailing Address - Fax:
Practice Address - Street 1:10400 S ROBERTS RD
Practice Address - Street 2:
Practice Address - City:PALOS HILLS
Practice Address - State:IL
Practice Address - Zip Code:60465-1972
Practice Address - Country:US
Practice Address - Phone:219-308-4891
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-04-20
Last Update Date:2021-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL160009225225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant