Basic Information
| Provider Information | |||||||||
| NPI: | 1689638066 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MOEN | ||||||||
| FirstName: | PATRICIA | ||||||||
| MiddleName: | A. | ||||||||
| NamePrefix: | MRS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.S., ATC | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | SCHANK | ||||||||
| OtherFirstName: | PATRICIA | ||||||||
| OtherMiddleName: | A. | ||||||||
| OtherNamePrefix: | MS. | ||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | M.S., ATC | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 750 E. TERRA COTTA AVE. | ||||||||
| Address2: | SUITE C | ||||||||
| City: | CRSYSTAL LAKE | ||||||||
| State: | IL | ||||||||
| PostalCode: | 60014 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8154550800 | ||||||||
| FaxNumber: | 8154552895 | ||||||||
| Practice Location | |||||||||
| Address1: | 1525 WEST LINCOLN HIGHWAY | ||||||||
| Address2: | CONVOCATION CENTER AT NORTHERN ILLINOIS UNIVERSITY | ||||||||
| City: | DEKALB | ||||||||
| State: | IL | ||||||||
| PostalCode: | 60115 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8157539477 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/13/2006 | ||||||||
| LastUpdateDate: | 02/01/2013 | ||||||||
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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 | 2255A2300X | 096-001286 | IL | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Specialist/Technologist | Athletic Trainer |
No ID Information.