Provider Demographics
NPI:1790908507
Name:CLAVECILLA, WILFREDO BERNARDO (PT)
Entity type:Individual
Prefix:
First Name:WILFREDO
Middle Name:BERNARDO
Last Name:CLAVECILLA
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2001 BUTTERFIELD RD STE 1600
Mailing Address - Street 2:
Mailing Address - City:DOWNERS GROVE
Mailing Address - State:IL
Mailing Address - Zip Code:60515-1211
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:6422 BELLS FERRY RD STE B-124
Practice Address - Street 2:
Practice Address - City:WOODSTOCK
Practice Address - State:GA
Practice Address - Zip Code:30189-6114
Practice Address - Country:US
Practice Address - Phone:770-372-1211
Practice Address - Fax:470-202-3291
Is Sole Proprietor?:No
Enumeration Date:2007-04-10
Last Update Date:2025-06-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAPT008523225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist