Provider Demographics
NPI:1174710032
Name:GERDES, REBECCA ELLEN (MS, DT)
Entity type:Individual
Prefix:MRS
First Name:REBECCA
Middle Name:ELLEN
Last Name:GERDES
Suffix:
Gender:F
Credentials:MS, DT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:635 N GROVE AVE
Mailing Address - Street 2:
Mailing Address - City:ELGIN
Mailing Address - State:IL
Mailing Address - Zip Code:60120-2803
Mailing Address - Country:US
Mailing Address - Phone:630-440-1015
Mailing Address - Fax:847-841-8529
Practice Address - Street 1:635 N GROVE AVE
Practice Address - Street 2:
Practice Address - City:ELGIN
Practice Address - State:IL
Practice Address - Zip Code:60120-2803
Practice Address - Country:US
Practice Address - Phone:630-440-1015
Practice Address - Fax:847-841-8529
Is Sole Proprietor?:Yes
Enumeration Date:2007-09-25
Last Update Date:2007-09-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ILRG21470903P222Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes222Q00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersDevelopmental Therapist