Basic Information
| Provider Information | |||||||||
| NPI: | 1083902043 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MILLS | ||||||||
| FirstName: | KASEY | ||||||||
| MiddleName: | DIANE | ||||||||
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| Credential: | PT | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1294 S ROUTE 12 | ||||||||
| Address2: | |||||||||
| City: | FOX LAKE | ||||||||
| State: | IL | ||||||||
| PostalCode: | 600201950 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8479739440 | ||||||||
| FaxNumber: | 8479739442 | ||||||||
| Practice Location | |||||||||
| Address1: | 1294 S ROUTE 12 | ||||||||
| Address2: | |||||||||
| City: | FOX LAKE | ||||||||
| State: | IL | ||||||||
| PostalCode: | 600201950 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8479739440 | ||||||||
| FaxNumber: | 8479739442 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/12/2011 | ||||||||
| LastUpdateDate: | 02/01/2016 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | 8672 | AZ | N | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist | 225100000X | 070019808 | IL | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
No ID Information.