Provider Demographics
NPI:1508092685
Name:DYNES, COURTNEY ODELSON (DPT)
Entity Type:Individual
Prefix:
First Name:COURTNEY
Middle Name:ODELSON
Last Name:DYNES
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:COURTNEY
Other - Middle Name:
Other - Last Name:ODELSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DPT
Mailing Address - Street 1:10401 S CICERO AVE
Mailing Address - Street 2:
Mailing Address - City:OAK LAWN
Mailing Address - State:IL
Mailing Address - Zip Code:60453-4703
Mailing Address - Country:US
Mailing Address - Phone:708-581-4810
Mailing Address - Fax:
Practice Address - Street 1:10401 S CICERO AVE
Practice Address - Street 2:
Practice Address - City:OAK LAWN
Practice Address - State:IL
Practice Address - Zip Code:60453-4703
Practice Address - Country:US
Practice Address - Phone:708-581-4810
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-06-03
Last Update Date:2017-04-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL070017277225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILF400264019Medicare PIN
ILF400264018Medicare PIN