Provider Demographics
NPI:1083609648
Name:STREETER, ERIC MICHAEL (MS, ATC)
Entity Type:Individual
Prefix:MR
First Name:ERIC
Middle Name:MICHAEL
Last Name:STREETER
Suffix:
Gender:M
Credentials:MS, ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2204 E TRAILSIDE DR N
Mailing Address - Street 2:
Mailing Address - City:MAHOMET
Mailing Address - State:IL
Mailing Address - Zip Code:61853-8512
Mailing Address - Country:US
Mailing Address - Phone:217-622-7175
Mailing Address - Fax:
Practice Address - Street 1:2040 S NEIL ST
Practice Address - Street 2:
Practice Address - City:CHAMPAIGN
Practice Address - State:IL
Practice Address - Zip Code:61820-7220
Practice Address - Country:US
Practice Address - Phone:217-352-3330
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-09-20
Last Update Date:2015-04-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL096-0017642255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL096-001764OtherLICENSED ATHLETIC TRAINER