Provider Demographics
NPI:1306213277
Name:SMITH, KATELYN J (PT)
Entity Type:Individual
Prefix:
First Name:KATELYN
Middle Name:J
Last Name:SMITH
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:KATELYN
Other - Middle Name:
Other - Last Name:SKINNER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PT
Mailing Address - Street 1:790 REMINGTON BLVD
Mailing Address - Street 2:
Mailing Address - City:BOLINGBROOK
Mailing Address - State:IL
Mailing Address - Zip Code:60440-4909
Mailing Address - Country:US
Mailing Address - Phone:630-296-2223
Mailing Address - Fax:
Practice Address - Street 1:12315 JUDSON RD
Practice Address - Street 2:
Practice Address - City:LIVE OAK
Practice Address - State:TX
Practice Address - Zip Code:78233-3277
Practice Address - Country:US
Practice Address - Phone:210-599-3090
Practice Address - Fax:210-599-4088
Is Sole Proprietor?:No
Enumeration Date:2015-08-27
Last Update Date:2017-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ILPT 070021791225100000X
TX1277063225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX569447ZK77OtherMEDICARE
ILF400243274Medicare UPIN