Provider Demographics
NPI:1669739165
Name:DETRICH, JOYCE (LMT)
Entity type:Individual
Prefix:
First Name:JOYCE
Middle Name:
Last Name:DETRICH
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:824 W CUYLER AVE
Mailing Address - Street 2:332
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60613-3281
Mailing Address - Country:US
Mailing Address - Phone:773-678-4002
Mailing Address - Fax:
Practice Address - Street 1:4007 N BROADWAY ST
Practice Address - Street 2:204
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60613-6074
Practice Address - Country:US
Practice Address - Phone:773-678-4002
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-04-20
Last Update Date:2012-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL227006915225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist