Provider Demographics
NPI:1073654448
Name:GIESE, MARY ELLEN BULOW (DPT)
Entity type:Individual
Prefix:
First Name:MARY ELLEN
Middle Name:BULOW
Last Name:GIESE
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:MARYELLEN
Other - Middle Name:
Other - Last Name:BULOW GIESE
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:DPT
Mailing Address - Street 1:2450 WOLF RD
Mailing Address - Street 2:SUITE E
Mailing Address - City:WESTCHESTER
Mailing Address - State:IL
Mailing Address - Zip Code:60154-5643
Mailing Address - Country:US
Mailing Address - Phone:708-492-1810
Mailing Address - Fax:708-492-1807
Practice Address - Street 1:2450 WOLF RD
Practice Address - Street 2:SUITE E
Practice Address - City:WESTCHESTER
Practice Address - State:IL
Practice Address - Zip Code:60154-5643
Practice Address - Country:US
Practice Address - Phone:708-492-1810
Practice Address - Fax:708-492-1807
Is Sole Proprietor?:No
Enumeration Date:2007-02-09
Last Update Date:2012-07-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL070012296225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist