Provider Demographics
NPI:1134363104
Name:DYBALA, ELLEN IRENE
Entity type:Individual
Prefix:MS
First Name:ELLEN
Middle Name:IRENE
Last Name:DYBALA
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 1:15420 WALNUT RD
Mailing Address - Street 2:
Mailing Address - City:OAK FOREST
Mailing Address - State:IL
Mailing Address - Zip Code:60452-1626
Mailing Address - Country:US
Mailing Address - Phone:708-687-7590
Mailing Address - Fax:
Practice Address - Street 1:15420 WALNUT RD
Practice Address - Street 2:
Practice Address - City:OAK FOREST
Practice Address - State:IL
Practice Address - Zip Code:60452-1626
Practice Address - Country:US
Practice Address - Phone:708-687-7590
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-04-21
Last Update Date:2009-04-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL146.001840235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist