Provider Demographics
NPI:1063645216
Name:DIETZEN, ANNEMARIE (DPT)
Entity Type:Individual
Prefix:
First Name:ANNEMARIE
Middle Name:
Last Name:DIETZEN
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:ANNEMARIE
Other - Middle Name:
Other - Last Name:PELLEGRENE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DPT
Mailing Address - Street 1:533 W NORTH AVE
Mailing Address - Street 2:SUITE 202
Mailing Address - City:ELMHURST
Mailing Address - State:IL
Mailing Address - Zip Code:60126-2135
Mailing Address - Country:US
Mailing Address - Phone:630-832-6919
Mailing Address - Fax:630-832-6928
Practice Address - Street 1:533 W NORTH AVE
Practice Address - Street 2:SUITE 202
Practice Address - City:ELMHURST
Practice Address - State:IL
Practice Address - Zip Code:60126-2135
Practice Address - Country:US
Practice Address - Phone:630-832-6919
Practice Address - Fax:630-832-6928
Is Sole Proprietor?:No
Enumeration Date:2009-09-03
Last Update Date:2011-02-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL070017371225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist