Provider Demographics
NPI:1659479871
Name:DIETRICK, ELLEN B (PT, DPT, PCS, C/NDT)
Entity Type:Individual
Prefix:
First Name:ELLEN
Middle Name:B
Last Name:DIETRICK
Suffix:
Gender:F
Credentials:PT, DPT, PCS, C/NDT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1033 E TALBOT ST
Mailing Address - Street 2:
Mailing Address - City:ARLINGTON HEIGHTS
Mailing Address - State:IL
Mailing Address - Zip Code:60004-5072
Mailing Address - Country:US
Mailing Address - Phone:847-253-9275
Mailing Address - Fax:
Practice Address - Street 1:3105 N WILKE RD
Practice Address - Street 2:SUITE H
Practice Address - City:ARLINGTON HEIGHTS
Practice Address - State:IL
Practice Address - Zip Code:60004-1495
Practice Address - Country:US
Practice Address - Phone:847-255-8690
Practice Address - Fax:847-255-2260
Is Sole Proprietor?:No
Enumeration Date:2006-09-20
Last Update Date:2014-06-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL070003470225100000X
2251P0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
No2251P0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistPediatrics