Provider Demographics
NPI:1437855913
Name:DEITERS, BRIDIE SUPPLE (PT)
Entity Type:Individual
Prefix:MS
First Name:BRIDIE
Middle Name:SUPPLE
Last Name:DEITERS
Suffix:
Gender:F
Credentials:PT
Other - Prefix:MISS
Other - First Name:BRIDIE
Other - Middle Name:A
Other - Last Name:SUPPLE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:7911 NORTHWOODS DR
Mailing Address - Street 2:
Mailing Address - City:FRANKFORT
Mailing Address - State:IL
Mailing Address - Zip Code:60423-9007
Mailing Address - Country:US
Mailing Address - Phone:708-307-5473
Mailing Address - Fax:
Practice Address - Street 1:7911 NORTHWOODS DR
Practice Address - Street 2:
Practice Address - City:FRANKFORT
Practice Address - State:IL
Practice Address - Zip Code:60423-9007
Practice Address - Country:US
Practice Address - Phone:708-307-5473
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-02-06
Last Update Date:2023-02-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL070015908225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist