Provider Demographics
NPI:1275888430
Name:KOOLIDGE, JOAN K (MPT)
Entity Type:Individual
Prefix:
First Name:JOAN
Middle Name:K
Last Name:KOOLIDGE
Suffix:
Gender:F
Credentials:MPT
Other - Prefix:
Other - First Name:JOAN
Other - Middle Name:E
Other - Last Name:KITCHENS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1952 ABERDEEN CT
Mailing Address - Street 2:
Mailing Address - City:SYCAMORE
Mailing Address - State:IL
Mailing Address - Zip Code:60178-3175
Mailing Address - Country:US
Mailing Address - Phone:815-758-0000
Mailing Address - Fax:815-748-3014
Practice Address - Street 1:900 N 2ND ST
Practice Address - Street 2:
Practice Address - City:ROCHELLE
Practice Address - State:IL
Practice Address - Zip Code:61068-1764
Practice Address - Country:US
Practice Address - Phone:815-758-0000
Practice Address - Fax:815-748-3014
Is Sole Proprietor?:No
Enumeration Date:2012-07-13
Last Update Date:2012-07-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL070009450174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist