Provider Demographics
NPI:1063779403
Name:RICHERT, DUSTIN (PT)
Entity type:Individual
Prefix:
First Name:DUSTIN
Middle Name:
Last Name:RICHERT
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15 APEX DR
Mailing Address - Street 2:
Mailing Address - City:HIGHLAND
Mailing Address - State:IL
Mailing Address - Zip Code:62249-1282
Mailing Address - Country:US
Mailing Address - Phone:618-589-9000
Mailing Address - Fax:618-589-9005
Practice Address - Street 1:210 HARTMAN LN STE 500
Practice Address - Street 2:
Practice Address - City:O FALLON
Practice Address - State:IL
Practice Address - Zip Code:62269-1783
Practice Address - Country:US
Practice Address - Phone:618-589-9000
Practice Address - Fax:618-589-9005
Is Sole Proprietor?:No
Enumeration Date:2012-04-23
Last Update Date:2012-04-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL070.016295225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist