Provider Demographics
NPI:1265887491
Name:ELLIS PEDIATRIC PHYSICAL THERAPY
Entity type:Organization
Organization Name:ELLIS PEDIATRIC PHYSICAL THERAPY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICAL THERAPIST
Authorized Official - Prefix:
Authorized Official - First Name:JULIETTE
Authorized Official - Middle Name:
Authorized Official - Last Name:ELLIS
Authorized Official - Suffix:
Authorized Official - Credentials:PT
Authorized Official - Phone:847-602-5016
Mailing Address - Street 1:433 OAKDALE AVE
Mailing Address - Street 2:
Mailing Address - City:GLENCOE
Mailing Address - State:IL
Mailing Address - Zip Code:60022-2112
Mailing Address - Country:US
Mailing Address - Phone:847-602-5016
Mailing Address - Fax:
Practice Address - Street 1:310 HAPP RD STE 310
Practice Address - Street 2:
Practice Address - City:NORTHFIELD
Practice Address - State:IL
Practice Address - Zip Code:60093-3455
Practice Address - Country:US
Practice Address - Phone:847-602-5016
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-04-25
Last Update Date:2016-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL070008366225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty