Provider Demographics
NPI:1699920074
Name:WESTENDORF, DANIELLE M
Entity type:Individual
Prefix:
First Name:DANIELLE
Middle Name:M
Last Name:WESTENDORF
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:DANIELLE
Other - Middle Name:M
Other - Last Name:DETERS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:901 MEDICAL PARK DR
Mailing Address - Street 2:SUITE 100
Mailing Address - City:EFFINGHAM
Mailing Address - State:IL
Mailing Address - Zip Code:62401-2191
Mailing Address - Country:US
Mailing Address - Phone:217-347-3003
Mailing Address - Fax:217-347-3005
Practice Address - Street 1:901 MEDICAL PARK DR
Practice Address - Street 2:SUITE 100
Practice Address - City:EFFINGHAM
Practice Address - State:IL
Practice Address - Zip Code:62401-2191
Practice Address - Country:US
Practice Address - Phone:217-347-3003
Practice Address - Fax:217-347-3005
Is Sole Proprietor?:No
Enumeration Date:2008-11-26
Last Update Date:2009-06-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL056008540225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
950854OtherHEALTHLINK
2500075OtherBCBS IL
568820001Medicare UPIN
IL568820Medicare PIN