Provider Demographics
NPI:1528200748
Name:RIETDYK, JULIE CRYSTAL (MS, OTR/L)
Entity Type:Individual
Prefix:
First Name:JULIE
Middle Name:CRYSTAL
Last Name:RIETDYK
Suffix:
Gender:F
Credentials:MS, OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:583 CLAYTON CIR
Mailing Address - Street 2:
Mailing Address - City:SYCAMORE
Mailing Address - State:IL
Mailing Address - Zip Code:60178-8908
Mailing Address - Country:US
Mailing Address - Phone:269-491-2969
Mailing Address - Fax:815-758-0717
Practice Address - Street 1:626 BETHANY RD
Practice Address - Street 2:
Practice Address - City:DEKALB
Practice Address - State:IL
Practice Address - Zip Code:60115-4939
Practice Address - Country:US
Practice Address - Phone:815-748-8900
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-04-02
Last Update Date:2009-04-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL056.008642225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist