Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 225200000X | Physical Therapy Assistant | 160.006158 | IL |
NPI | 1003278946 |
---|---|
Provider Name | Beverly Ehlebracht |
First Address | Chicago, IL 60674-0001 |
Second Address | Woodrige, IL 60517 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 21/03/2016 |
Last Update Date | 21/03/2016 |