Basic Information
| Provider Information | |||||||||
| NPI: | 1477205474 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | JOHNSON | ||||||||
| FirstName: | KATLYN | ||||||||
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| Credential: | LAT, ATC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4547 N KARLOV AVE | ||||||||
| Address2: | |||||||||
| City: | CHICAGO | ||||||||
| State: | IL | ||||||||
| PostalCode: | 606304401 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7733839708 | ||||||||
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| Practice Location | |||||||||
| Address1: | 50 E NORTHWEST HWY | ||||||||
| Address2: | |||||||||
| City: | MOUNT PROSPECT | ||||||||
| State: | IL | ||||||||
| PostalCode: | 600563223 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8477189201 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 01/20/2022 | ||||||||
| LastUpdateDate: | 01/20/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 01/20/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2255A2300X | 096005233 | IL | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Specialist/Technologist | Athletic Trainer |
No ID Information.