Provider Demographics
NPI:1366142093
Name:VAAL, SAMANTHA JAE (DPT, PTA, RYT-200)
Entity type:Individual
Prefix:MRS
First Name:SAMANTHA
Middle Name:JAE
Last Name:VAAL
Suffix:
Gender:F
Credentials:DPT, PTA, RYT-200
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4850 KINGS WAY W
Mailing Address - Street 2:
Mailing Address - City:GURNEE
Mailing Address - State:IL
Mailing Address - Zip Code:60031-3255
Mailing Address - Country:US
Mailing Address - Phone:812-449-2558
Mailing Address - Fax:
Practice Address - Street 1:900 N WESTMORELAND RD
Practice Address - Street 2:
Practice Address - City:LAKE FOREST
Practice Address - State:IL
Practice Address - Zip Code:60045-1674
Practice Address - Country:US
Practice Address - Phone:630-933-1500
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-03-09
Last Update Date:2023-03-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL160.009775225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant