Provider Demographics
NPI:1366680894
Name:ROSKA-DIZON, ANNA RUSELLE E (RPT)
Entity Type:Individual
Prefix:MRS
First Name:ANNA RUSELLE
Middle Name:E
Last Name:ROSKA-DIZON
Suffix:
Gender:F
Credentials:RPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6655 WEST PINE LAKE DR
Mailing Address - Street 2:
Mailing Address - City:TINLEY PARK
Mailing Address - State:IL
Mailing Address - Zip Code:60477-4934
Mailing Address - Country:US
Mailing Address - Phone:708-263-5245
Mailing Address - Fax:
Practice Address - Street 1:3703 W LAKE AVE
Practice Address - Street 2:SUITE 200
Practice Address - City:GLENVIEW
Practice Address - State:IL
Practice Address - Zip Code:60026-5823
Practice Address - Country:US
Practice Address - Phone:847-998-1188
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-01-21
Last Update Date:2009-01-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL070015745225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist