Provider Demographics
NPI:1235301458
Name:IBSEN, DAWNELL (PT)
Entity Type:Individual
Prefix:
First Name:DAWNELL
Middle Name:
Last Name:IBSEN
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1860 PAYSPHERE CIR
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60674-0018
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:430 PENNSYLVANIA AVE
Practice Address - Street 2:STE 240
Practice Address - City:GLEN ELLYN
Practice Address - State:IL
Practice Address - Zip Code:60137-4418
Practice Address - Country:US
Practice Address - Phone:630-545-7801
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-03-27
Last Update Date:2021-06-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL070005277225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL$$$$$$$$$001Medicaid