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General NPI Number Information
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NPI Number | 1265887491
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Entity Type | Organization
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Legal Business Name | ELLIS PEDIATRIC PHYSICAL THERAPY
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Dates
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Enumeration Date | 04/25/2016
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Last Update Date | 04/25/2016
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Provider Practice Location Address
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Address Line | 310 HAPP RD STE 310
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City | NORTHFIELD
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State | IL
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Zip | 60093-3455
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Country | US
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Telephone | 847-602-5016
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Fax |
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Provider Business Mailing Address
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Address Line | 433 OAKDALE AVE
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City | GLENCOE
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State | IL
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Zip | 60022-2112
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Country | US
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Telephone | 847-602-5016
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Fax |
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Authorized Official
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Title or Position | PHYSICAL THERAPIST
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Name | JULIETTE ELLIS
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Credential | P.T.
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Telephone | 847-602-5016
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 225100000X
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Taxonomy Name | Physical Therapist
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License Number | 070008366
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License Number State | IL
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