Provider Demographics
NPI:1295512614
Name:DENEAL, AMETHYST (PT, DPT)
Entity type:Individual
Prefix:
First Name:AMETHYST
Middle Name:
Last Name:DENEAL
Suffix:
Gender:F
Credentials:PT, DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:545 WOMBLE RD
Mailing Address - Street 2:
Mailing Address - City:HARRISBURG
Mailing Address - State:IL
Mailing Address - Zip Code:62946-5457
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1201 RICKER RD
Practice Address - Street 2:
Practice Address - City:SALEM
Practice Address - State:IL
Practice Address - Zip Code:62881-4263
Practice Address - Country:US
Practice Address - Phone:618-548-3194
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-09-11
Last Update Date:2024-02-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL070028003225100000X
VA2305215820225100000X
NCP22182225100000X
KY008989225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist