Provider Demographics
NPI:1538393483
Name:PATES, DJEDAH (PT)
Entity type:Individual
Prefix:MISS
First Name:DJEDAH
Middle Name:
Last Name:PATES
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1243 JUDSON AVE
Mailing Address - Street 2:APT 1
Mailing Address - City:EVANSTON
Mailing Address - State:IL
Mailing Address - Zip Code:60202-1388
Mailing Address - Country:US
Mailing Address - Phone:847-859-2372
Mailing Address - Fax:847-859-2372
Practice Address - Street 1:2710 N CLARK ST
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60614-1503
Practice Address - Country:US
Practice Address - Phone:773-244-0005
Practice Address - Fax:773-244-0006
Is Sole Proprietor?:Yes
Enumeration Date:2009-05-06
Last Update Date:2009-05-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL070015089225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist