Healthcare Provider Details

I. General information

NPI: 1134363104
Provider Name (Legal Business Name): MS. ELLEN IRENE DYBALA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/21/2009
Last Update Date: 04/21/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

15420 WALNUT RD
OAK FOREST IL
60452-1626
US

IV. Provider business mailing address

15420 WALNUT RD
OAK FOREST IL
60452-1626
US

V. Phone/Fax

Practice location:
  • Phone: 708-687-7590
  • Fax:
Mailing address:
  • Phone: 708-687-7590
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number146.001840
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: