Healthcare Provider Details

I. General information

NPI: 1972433993
Provider Name (Legal Business Name): ETHAN DAVID PT, DPT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/21/2026
Last Update Date: 05/21/2026
Certification Date: 05/21/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

23915 W MAIN ST UNIT 109
PLAINFIELD IL
60544-1993
US

IV. Provider business mailing address

11016 HALEY CT
ORLAND PARK IL
60467-5667
US

V. Phone/Fax

Practice location:
  • Phone: 815-296-0596
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number070.039858
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: