Basic Information
| Provider Information | |||||||||
| NPI: | 1942450515 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | KOOYENGA | ||||||||
| FirstName: | CARRIE | ||||||||
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| Credential: | PTA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 10100 FOREST HILLS RD | ||||||||
| Address2: | |||||||||
| City: | MACHESNEY PARK | ||||||||
| State: | IL | ||||||||
| PostalCode: | 611158234 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8157132742 | ||||||||
| FaxNumber: | 8152828597 | ||||||||
| Practice Location | |||||||||
| Address1: | 1663 BELVIDERE RD | ||||||||
| Address2: | |||||||||
| City: | BELVIDERE | ||||||||
| State: | IL | ||||||||
| PostalCode: | 610089306 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8155440040 | ||||||||
| FaxNumber: | 8155440048 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/19/2008 | ||||||||
| LastUpdateDate: | 09/19/2008 | ||||||||
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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 | 225200000X | 160.005053 | IL | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapy Assistant |
ID Information
| ID | Type | State | Issuer | Description | 160.005053 | 01 | IL | STATE OF ILLINOIS LICENSE | OTHER |