1023635364 NPI number — MRS. CRYSTAL MARY DIRKS COTA/L

Table of content: DAPHNE THAYER BARRETT LMT (NPI 1003241092)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1023635364 NPI number — MRS. CRYSTAL MARY DIRKS COTA/L

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
DIRKS
Provider First Name:
CRYSTAL
Provider Middle Name:
MARY
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
COTA/L
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
PEDZIEWIATR
Provider Other First Name:
CRYSTAL
Provider Other Middle Name:
MARY
Provider Other Name Prefix Text:
MISS
Provider Other Name Suffix Text:
Provider Other Credential Text:
COTA/L
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1023635364
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/02/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1S221 EUCLID AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
VILLA PARK
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
60181-3902
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
630-995-0408
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
211 75TH ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BURR RIDGE
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
60527
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
630-230-1170
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
07/02/2020

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 224Z00000X , with the licence number:  057004588 , registered in the state of IL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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