Provider Demographics
NPI:1043413958
Name:BOTTRELL, ELIZABETH SIERRA (MPT)
Entity Type:Individual
Prefix:
First Name:ELIZABETH
Middle Name:SIERRA
Last Name:BOTTRELL
Suffix:
Gender:F
Credentials:MPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5764 S ARCHER AVE
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60638-1643
Mailing Address - Country:US
Mailing Address - Phone:773-284-0888
Mailing Address - Fax:773-284-0880
Practice Address - Street 1:5764 S ARCHER AVE
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60638-1643
Practice Address - Country:US
Practice Address - Phone:773-284-0888
Practice Address - Fax:773-284-0880
Is Sole Proprietor?:No
Enumeration Date:2007-06-07
Last Update Date:2010-07-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL070017163225100000X
WI10760-24225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL1633794OtherBLUE CROSS BLUE SHIELD
IL1633794OtherBLUE CROSS BLUE SHIELD
IL208542Medicare PIN