Healthcare Provider Details

I. General information

NPI: 1114167483
Provider Name (Legal Business Name): JULIE DYBALA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/26/2009
Last Update Date: 02/26/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1733 W IRVING PARK RD APT. #206
CHICAGO IL
60613-2500
US

IV. Provider business mailing address

1733 W IRVING PARK RD APT. # 206
CHICAGO IL
60613-2500
US

V. Phone/Fax

Practice location:
  • Phone: 708-263-5757
  • Fax:
Mailing address:
  • Phone: 708-263-5757
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225800000X
TaxonomyRecreation Therapist
License Number40289
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: