Provider Demographics
NPI:1023239142
Name:JULIE M LEIDECKER LTD
Entity type:Organization
Organization Name:JULIE M LEIDECKER LTD
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANGER
Authorized Official - Prefix:
Authorized Official - First Name:CINDY
Authorized Official - Middle Name:
Authorized Official - Last Name:GERARD
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:815-935-0540
Mailing Address - Street 1:586 WILLIAM R LATHAM SR DR STE 6B
Mailing Address - Street 2:
Mailing Address - City:BOURBONNAIS
Mailing Address - State:IL
Mailing Address - Zip Code:60914-2338
Mailing Address - Country:US
Mailing Address - Phone:815-935-0540
Mailing Address - Fax:
Practice Address - Street 1:586 WILLIAM R LATHAM SR DR STE 6B
Practice Address - Street 2:
Practice Address - City:BOURBONNAIS
Practice Address - State:IL
Practice Address - Zip Code:60914-2338
Practice Address - Country:US
Practice Address - Phone:815-935-0540
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-02
Last Update Date:2008-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL1447301643OtherJ LEIDECKER NPI
IL1861543068OtherC ANDERSON NPI
IL341746853001OtherC ANDERSON
IL358701965001Medicaid