Provider Demographics
NPI:1013475888
Name:PELIKAN, CHRISTINE MARIE
Entity type:Individual
Prefix:
First Name:CHRISTINE
Middle Name:MARIE
Last Name:PELIKAN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:323 RIDGE DR
Mailing Address - Street 2:
Mailing Address - City:DEKALB
Mailing Address - State:IL
Mailing Address - Zip Code:60115-1741
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:323 RIDGE DR
Practice Address - Street 2:
Practice Address - City:DEKALB
Practice Address - State:IL
Practice Address - Zip Code:60115-1741
Practice Address - Country:US
Practice Address - Phone:815-761-5826
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-03-11
Last Update Date:2019-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL222Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes222Q00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersDevelopmental Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL222Q00000XMedicaid