Basic Information
| Provider Information | |||||||||
| NPI: | 1124264478 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | KNOLL | ||||||||
| FirstName: | THERESA | ||||||||
| MiddleName: | ANN | ||||||||
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| Credential: | MPT | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | YANIK | ||||||||
| OtherFirstName: | THERESA | ||||||||
| OtherMiddleName: | ANN | ||||||||
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| OtherCredential: | MPT | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 210 SE PIONEER WAY | ||||||||
| Address2: | STE 2 | ||||||||
| City: | OAK HARBOR | ||||||||
| State: | WA | ||||||||
| PostalCode: | 982775705 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3606798600 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 3475 S ALPINE RD | ||||||||
| Address2: | PHYSICIANS IMMEDIATE CARE | ||||||||
| City: | ROCKFORD | ||||||||
| State: | IL | ||||||||
| PostalCode: | 611092604 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8158748000 | ||||||||
| FaxNumber: | 8158747525 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/16/2008 | ||||||||
| LastUpdateDate: | 10/09/2017 | ||||||||
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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 | 8149 | TN | N | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist | 225100000X | 070017118 | IL | N | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist | 225100000X | PT60736405 | WA | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
ID Information
| ID | Type | State | Issuer | Description | 769380 | 01 | IL | MEDICARE GROUP PTAN | OTHER | 10115176 | 01 | IL | BCBS GRP # | OTHER |