Basic Information
| Provider Information | |||||||||
| NPI: | 1700397064 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | STEVENS | ||||||||
| FirstName: | KELLY | ||||||||
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| Credential: | PT, DPT | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1000 REMINGTON BLVD | ||||||||
| Address2: | STE 100 | ||||||||
| City: | BOLINGBROOK | ||||||||
| State: | IL | ||||||||
| PostalCode: | 604404707 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6309142898 | ||||||||
| FaxNumber: | 6309142469 | ||||||||
| Practice Location | |||||||||
| Address1: | 2845 N SHERIDAN RD | ||||||||
| Address2: | SUITE 6400 | ||||||||
| City: | CHICAGO | ||||||||
| State: | IL | ||||||||
| PostalCode: | 60657 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7736658400 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 10/13/2017 | ||||||||
| LastUpdateDate: | 11/20/2017 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | 070023222 | IL | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
No ID Information.