Provider Demographics
NPI:1063665305
Name:STREET, KAREN D (PTA)
Entity Type:Individual
Prefix:
First Name:KAREN
Middle Name:D
Last Name:STREET
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1315 CURT DR
Mailing Address - Street 2:
Mailing Address - City:CHAMPAIGN
Mailing Address - State:IL
Mailing Address - Zip Code:61821-1167
Mailing Address - Country:US
Mailing Address - Phone:217-352-9334
Mailing Address - Fax:217-352-9324
Practice Address - Street 1:1315 CURT DR
Practice Address - Street 2:
Practice Address - City:CHAMPAIGN
Practice Address - State:IL
Practice Address - Zip Code:61821-1167
Practice Address - Country:US
Practice Address - Phone:217-352-9334
Practice Address - Fax:217-352-9324
Is Sole Proprietor?:Yes
Enumeration Date:2008-10-30
Last Update Date:2008-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL160001486225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant