Provider Demographics
NPI:1801506266
Name:SENICA, ELLIE NICOLE
Entity type:Individual
Prefix:
First Name:ELLIE
Middle Name:NICOLE
Last Name:SENICA
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 1:2144 E 550TH RD
Mailing Address - Street 2:
Mailing Address - City:OGLESBY
Mailing Address - State:IL
Mailing Address - Zip Code:61348-9646
Mailing Address - Country:US
Mailing Address - Phone:815-830-9472
Mailing Address - Fax:
Practice Address - Street 1:2111 MIDLANDS CT STE 203
Practice Address - Street 2:
Practice Address - City:SYCAMORE
Practice Address - State:IL
Practice Address - Zip Code:60178-3125
Practice Address - Country:US
Practice Address - Phone:815-758-0000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-11-28
Last Update Date:2022-11-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL070027122225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist