Basic Information
| Provider Information | |||||||||
| NPI: | 1821406869 | ||||||||
| EntityType: | 1 | ||||||||
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| LastName: | IPSEN | ||||||||
| FirstName: | PRIYA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 550 FRONTAGE RD SUITE 2415 | ||||||||
| Address2: | SELECT REHABILITATION | ||||||||
| City: | NORTHFIELD | ||||||||
| State: | IL | ||||||||
| PostalCode: | 60093 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8777873422 | ||||||||
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| Practice Location | |||||||||
| Address1: | 2304 COUNTY RD 3000 N | ||||||||
| Address2: | COUNTRY HEALTH CARE & REHAB | ||||||||
| City: | GIFFORD | ||||||||
| State: | IL | ||||||||
| PostalCode: | 61847 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2175687362 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 07/22/2014 | ||||||||
| LastUpdateDate: | 07/22/2014 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225200000X | 160.003278 | IL | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapy Assistant |
No ID Information.