Provider Demographics
NPI:1972527166
Name:DIERCKS, ELLIE SUE
Entity type:Individual
Prefix:
First Name:ELLIE
Middle Name:SUE
Last Name:DIERCKS
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 1:21880 COUNTY 9 BLVD
Mailing Address - Street 2:
Mailing Address - City:GOODHUE
Mailing Address - State:MN
Mailing Address - Zip Code:55027-8233
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:701 FAIRVIEW BLVD
Practice Address - Street 2:
Practice Address - City:RED WING
Practice Address - State:MN
Practice Address - Zip Code:55066-2848
Practice Address - Country:US
Practice Address - Phone:651-267-5000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-27
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist