Provider Demographics
NPI:1750601498
Name:DAHM, MARY ELLEN (PTA)
Entity type:Individual
Prefix:MS
First Name:MARY
Middle Name:ELLEN
Last Name:DAHM
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9011 MCVICKER AVE
Mailing Address - Street 2:
Mailing Address - City:MORTON GROVE
Mailing Address - State:IL
Mailing Address - Zip Code:60053-2422
Mailing Address - Country:US
Mailing Address - Phone:184-796-6621
Mailing Address - Fax:
Practice Address - Street 1:9011 MCVICKER AVE
Practice Address - Street 2:
Practice Address - City:MORTON GROVE
Practice Address - State:IL
Practice Address - Zip Code:60053-2422
Practice Address - Country:US
Practice Address - Phone:184-796-6621
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-06-04
Last Update Date:2010-06-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL160001369225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant