Healthcare Provider Details

I. General information

NPI: 1780879908
Provider Name (Legal Business Name): JULIETTE RACHEL ELLIS P.T.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/11/2007
Last Update Date: 09/09/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

433 OAKDALE AVE
GLENCOE IL
60022-2112
US

IV. Provider business mailing address

433 OAKDALE AVE
GLENCOE IL
60022-2112
US

V. Phone/Fax

Practice location:
  • Phone: 847-602-5016
  • Fax:
Mailing address:
  • Phone: 847-602-5016
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number070008366
License Number StateIL
# 2
Primary TaxonomyY
Taxonomy Code2251P0200X
TaxonomyPediatric Physical Therapist
License Number070008366
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: