Healthcare Provider Details

I. General information

NPI: 1457744930
Provider Name (Legal Business Name): DIPTI BHALE
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/09/2015
Last Update Date: 06/01/2021
Certification Date: 06/01/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

465 W LEATHER AVE APT 5
TOMAHAWK WI
54487-2270
US

IV. Provider business mailing address

38 S MAIN ST APT A
SUGAR GROVE IL
60554-5031
US

V. Phone/Fax

Practice location:
  • Phone: 405-714-0919
  • Fax:
Mailing address:
  • Phone: 630-466-5866
  • Fax: 630-466-5869

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number12236-24
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: