Provider Demographics
NPI:1376010678
Name:KIKUGAWA, TERESA MICHELLE (DAT, LAT, ATC)
Entity Type:Individual
Prefix:DR
First Name:TERESA
Middle Name:MICHELLE
Last Name:KIKUGAWA
Suffix:
Gender:F
Credentials:DAT, LAT, ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:645 HIBBARD RD
Mailing Address - Street 2:
Mailing Address - City:WILMETTE
Mailing Address - State:IL
Mailing Address - Zip Code:60091-2042
Mailing Address - Country:US
Mailing Address - Phone:360-701-3449
Mailing Address - Fax:
Practice Address - Street 1:633 EMERSON ST
Practice Address - Street 2:
Practice Address - City:EVANSTON
Practice Address - State:IL
Practice Address - Zip Code:60208-0844
Practice Address - Country:US
Practice Address - Phone:847-467-5415
Practice Address - Fax:847-491-2120
Is Sole Proprietor?:No
Enumeration Date:2018-10-25
Last Update Date:2018-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL096.0046992255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer