Provider Demographics
NPI:1164053526
Name:VICKERS, KAYLA CHRISTINE (PT, DPT, CMTPT)
Entity Type:Individual
Prefix:
First Name:KAYLA
Middle Name:CHRISTINE
Last Name:VICKERS
Suffix:
Gender:F
Credentials:PT, DPT, CMTPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1715 PLOVER RD
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:IL
Mailing Address - Zip Code:62711-7925
Mailing Address - Country:US
Mailing Address - Phone:217-836-4320
Mailing Address - Fax:
Practice Address - Street 1:1600 W WALNUT ST
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:IL
Practice Address - Zip Code:62650-1136
Practice Address - Country:US
Practice Address - Phone:217-245-9541
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-02-03
Last Update Date:2020-02-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL070022185225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist