Provider Demographics
NPI:1275860694
Name:SKOTNICKI, COLLEEN (PT)
Entity Type:Individual
Prefix:
First Name:COLLEEN
Middle Name:
Last Name:SKOTNICKI
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1250 GOLDFINCH LN
Mailing Address - Street 2:
Mailing Address - City:ANTIOCH
Mailing Address - State:IL
Mailing Address - Zip Code:60002-6410
Mailing Address - Country:US
Mailing Address - Phone:847-977-7188
Mailing Address - Fax:
Practice Address - Street 1:23408 W APOLLO CT
Practice Address - Street 2:
Practice Address - City:LAKE VILLA
Practice Address - State:IL
Practice Address - Zip Code:60046-9638
Practice Address - Country:US
Practice Address - Phone:847-856-9014
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-11-05
Last Update Date:2016-12-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL070013436225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist