Provider Demographics
NPI:1518059203
Name:WEGRZYN, ELLEN M (PT)
Entity Type:Individual
Prefix:
First Name:ELLEN
Middle Name:M
Last Name:WEGRZYN
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:ELLEN
Other - Middle Name:M
Other - Last Name:NOWICKI
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PT
Mailing Address - Street 1:790 REMINGTON BLVD
Mailing Address - Street 2:
Mailing Address - City:BOLINGBROOK
Mailing Address - State:IL
Mailing Address - Zip Code:60440-4909
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2499 E JOLIET HWY
Practice Address - Street 2:UNIT 112
Practice Address - City:NEW LENOX
Practice Address - State:IL
Practice Address - Zip Code:60451-2592
Practice Address - Country:US
Practice Address - Phone:630-462-9420
Practice Address - Fax:630-462-9421
Is Sole Proprietor?:No
Enumeration Date:2006-09-29
Last Update Date:2014-07-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL070005278225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILF400144846Medicare PIN
ILF400144847Medicare PIN
ILP00417721Medicare PIN
ILK22480Medicare PIN