Provider Demographics
NPI:1710586151
Name:MORITA, DANE B (PT)
Entity Type:Individual
Prefix:MR
First Name:DANE
Middle Name:B
Last Name:MORITA
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:550 S CEDAR AVE
Mailing Address - Street 2:
Mailing Address - City:ELMHURST
Mailing Address - State:IL
Mailing Address - Zip Code:60126-4136
Mailing Address - Country:US
Mailing Address - Phone:630-290-1148
Mailing Address - Fax:
Practice Address - Street 1:550 S CEDAR AVE
Practice Address - Street 2:
Practice Address - City:ELMHURST
Practice Address - State:IL
Practice Address - Zip Code:60126-4136
Practice Address - Country:US
Practice Address - Phone:630-290-1148
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-10-17
Last Update Date:2020-10-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ILO7O.005137225100000X
IL070005137225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist