Provider Demographics
NPI:1487605713
Name:BALDACCI, DIANE L (PT)
Entity type:Individual
Prefix:MS
First Name:DIANE
Middle Name:L
Last Name:BALDACCI
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 1:2736 BIMINI LN
Mailing Address - Street 2:
Mailing Address - City:NEW LENOX
Mailing Address - State:IL
Mailing Address - Zip Code:60451-9206
Mailing Address - Country:US
Mailing Address - Phone:815-463-1770
Mailing Address - Fax:
Practice Address - Street 1:2701 W 68TH ST
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60629-1813
Practice Address - Country:US
Practice Address - Phone:773-884-4810
Practice Address - Fax:773-884-8093
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-12
Last Update Date:2012-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL070-002935225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist