Provider Demographics
NPI:1063656163
Name:MECKSTROTH, NATALIE R (MA, ATC)
Entity Type:Individual
Prefix:
First Name:NATALIE
Middle Name:R
Last Name:MECKSTROTH
Suffix:
Gender:F
Credentials:MA, ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1525 W LINCOLN HWY
Mailing Address - Street 2:
Mailing Address - City:DEKALB
Mailing Address - State:IL
Mailing Address - Zip Code:60115-3989
Mailing Address - Country:US
Mailing Address - Phone:815-753-9477
Mailing Address - Fax:815-753-1402
Practice Address - Street 1:1525 W LINCOLN HWY
Practice Address - Street 2:
Practice Address - City:DEKALB
Practice Address - State:IL
Practice Address - Zip Code:60115-3989
Practice Address - Country:US
Practice Address - Phone:815-753-9477
Practice Address - Fax:815-753-1402
Is Sole Proprietor?:No
Enumeration Date:2009-04-21
Last Update Date:2009-04-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL096.0021872255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer