Active NPI
Kenneth-Albert Fababaer Valenzuela, PT
- Physical Therapist
- Forest Park, IL
National Provider Identifier
1558779876
On this page
Key facts
NPPES NPI Registry- Primary specialty
- Physical Therapist
- License
- 070020735
- Practice address
- 7440 Harrison St Apt 2
Forest Park, IL 60130-2085 - Phone
- (708) 790-9577
- NPI assigned
- Jul 30, 2014
- Sex
- Male
- Sole proprietor
- Yes
NPPES NPI Registry
Registry information is reported by the provider to CMS and is not verified. About this source
Specialties & licenses 2
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Physical Therapist | 225100000X | 070020735 | IL | Primary |
| Physical Therapist | 225100000X | J1-0003168 | DE |
Addresses
Primary practice location
7440 Harrison St Apt 2
Forest Park, IL 60130-2085
Mailing address
7440 Harrison St Apt 2
Forest Park, IL 60130-2085
Medicare participation
Medicare enrollment files- Medicare fee-for-service enrollment
- Enrolled in IL
Enrollment records 1
| Enrollment ID | State | Provider type | PAC ID | Details |
|---|---|---|---|---|
| I20190807001899 | IL | Practitioner - Physical Therapist in Private Practice | 0648507103 | Reassigns benefits to 1 organization |
National Provider Directory
National Provider Directory- Medicare enrollment (NPD)
- Enrolled
State licenses
| License | State | Type | Specialty |
|---|---|---|---|
| J1-0003168 | DE | MD | Physical Therapist |
| 070020735 | IL | MD | Physical Therapist |
Organizations & group practices 1
Organizations this provider is connected to: Medicare benefit reassignments (the organization bills Medicare for this provider’s services), Care Compare group memberships and National Provider Directory roles.
NPI Registry JSON
The complete NPPES record for this NPI in the NPI Registry API format.
{
"created_epoch": "1406678400000",
"enumeration_type": "NPI-1",
"last_updated_epoch": "1406678400000",
"number": "1558779876",
"addresses": [
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "MAILING",
"address_type": "DOM",
"address_1": "7440 HARRISON ST APT 2",
"city": "FOREST PARK",
"state": "IL",
"postal_code": "601302085"
},
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "LOCATION",
"address_type": "DOM",
"address_1": "7440 HARRISON ST APT 2",
"city": "FOREST PARK",
"state": "IL",
"postal_code": "601302085",
"telephone_number": "708-790-9577"
}
],
"practiceLocations": [],
"basic": {
"last_name": "VALENZUELA",
"first_name": "KENNETH-ALBERT",
"middle_name": "FABABAER",
"name_prefix": "Mr.",
"credential": "PT",
"sole_proprietor": "YES",
"sex": "M",
"enumeration_date": "2014-07-30",
"last_updated": "2014-07-30",
"status": "A"
},
"taxonomies": [
{
"code": "225100000X",
"taxonomy_group": "",
"desc": "Physical Therapist",
"state": "IL",
"license": "070020735",
"primary": true
},
{
"code": "225100000X",
"taxonomy_group": "",
"desc": "Physical Therapist",
"state": "DE",
"license": "J1-0003168",
"primary": false
}
],
"identifiers": [],
"endpoints": [],
"other_names": []
}Other providers in Forest Park, IL
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Jul 30, 2014; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
- Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.