Provider Demographics
NPI:1235884123
Name:KATTAKAYAM, ABRAHAM JOSE
Entity Type:Individual
Prefix:
First Name:ABRAHAM
Middle Name:JOSE
Last Name:KATTAKAYAM
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6105 W GRACE ST
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60634-2549
Mailing Address - Country:US
Mailing Address - Phone:312-978-1703
Mailing Address - Fax:
Practice Address - Street 1:66 W OAK ST
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60610-7325
Practice Address - Country:US
Practice Address - Phone:312-978-1703
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-02-18
Last Update Date:2022-02-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL070023719225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty