Provider Demographics
NPI:1548882152
Name:REYES, MICHAELA (DPT)
Entity type:Individual
Prefix:
First Name:MICHAELA
Middle Name:
Last Name:REYES
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:MICHAELA
Other - Middle Name:
Other - Last Name:NIEMEYER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DPT
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 1:1612 S NEIL ST
Practice Address - Street 2:
Practice Address - City:CHAMPAIGN
Practice Address - State:IL
Practice Address - Zip Code:61820-4037
Practice Address - Country:US
Practice Address - Phone:217-355-1961
Practice Address - Fax:217-355-1963
Is Sole Proprietor?:Yes
Enumeration Date:2020-05-18
Last Update Date:2022-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI2227-392255A2300X
IL070-025217225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
No2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer