=====================================================
General NPI Number Information
=====================================================
NPI Number | 1720311509
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | EILEEN M DEXHEIMER PT
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/11/2009
-----------------------------------------------------
Last Update Date | 09/11/2009
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 660 N WESTMORELAND RD
-----------------------------------------------------
City | LAKE FOREST
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60045-1659
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 847-535-6520
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2917 LIBERTY LN
-----------------------------------------------------
City | LINDENHURST
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60046-7893
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 847-265-6825
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 225100000X
-----------------------------------------------------
Taxonomy Name | Physical Therapist
-----------------------------------------------------
License Number | 070-005226
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------