Basic Information
| Provider Information | |||||||||
| NPI: | 1710077557 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | WAX | ||||||||
| FirstName: | KATHERINE | ||||||||
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| Credential: | PT | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1850 W OAKDALE AVE | ||||||||
| Address2: | |||||||||
| City: | CHICAGO | ||||||||
| State: | IL | ||||||||
| PostalCode: | 60657 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8158342400 | ||||||||
| FaxNumber: | 8158342424 | ||||||||
| Practice Location | |||||||||
| Address1: | 7225 W COLLEGE DR | ||||||||
| Address2: | |||||||||
| City: | PALOS HEIGHTS | ||||||||
| State: | IL | ||||||||
| PostalCode: | 604631101 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7083615355 | ||||||||
| FaxNumber: | 7083615399 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/13/2006 | ||||||||
| LastUpdateDate: | 09/24/2013 | ||||||||
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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 | 225100000X | 070-014502 | IL | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
ID Information
| ID | Type | State | Issuer | Description | P00238078 | 01 | IL | R.R. MEDICARE PIN # | OTHER | CJ4383 | 01 | IL | R.R. MEDICARE GRP# | OTHER | 1623066 | 01 | IL | BCBS PROVIDER # | OTHER | 367885100 | 01 | IL | US DEPT OF LABOR PROV # | OTHER |