Provider Demographics
NPI:1750677340
Name:WELTER, ELLEN (PT)
Entity Type:Individual
Prefix:
First Name:ELLEN
Middle Name:
Last Name:WELTER
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:814 HILLGROVE AVE
Mailing Address - Street 2:
Mailing Address - City:WESTERN SPRINGS
Mailing Address - State:IL
Mailing Address - Zip Code:60558-1439
Mailing Address - Country:US
Mailing Address - Phone:708-505-3900
Mailing Address - Fax:708-505-4647
Practice Address - Street 1:814 HILLGROVE AVE
Practice Address - Street 2:
Practice Address - City:WESTERN SPRINGS
Practice Address - State:IL
Practice Address - Zip Code:60558-1439
Practice Address - Country:US
Practice Address - Phone:708-505-3900
Practice Address - Fax:708-505-4647
Is Sole Proprietor?:No
Enumeration Date:2011-06-22
Last Update Date:2014-04-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL070018440225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL070018440Medicaid