Provider Demographics
NPI:1831218056
Name:ELLBOGEN, CHRISTOPHER MICHAL (MT)
Entity type:Individual
Prefix:MR
First Name:CHRISTOPHER
Middle Name:MICHAL
Last Name:ELLBOGEN
Suffix:
Gender:M
Credentials:MT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1418 WHITESPIRE CT
Mailing Address - Street 2:
Mailing Address - City:NAPERVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:60565-2031
Mailing Address - Country:US
Mailing Address - Phone:630-961-9636
Mailing Address - Fax:
Practice Address - Street 1:552 S WASHINGTON ST
Practice Address - Street 2:SUITE 117
Practice Address - City:NAPERVILLE
Practice Address - State:IL
Practice Address - Zip Code:60540-6658
Practice Address - Country:US
Practice Address - Phone:630-961-9636
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-28
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist