Provider Demographics
NPI:1376558734
Name:ENLOE, KATY IRENE (PT)
Entity Type:Individual
Prefix:
First Name:KATY
Middle Name:IRENE
Last Name:ENLOE
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:KATY
Other - Middle Name:IRENE
Other - Last Name:BEWLEY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PT
Mailing Address - Street 1:530 NE GLEN OAK AVE
Mailing Address - Street 2:
Mailing Address - City:PEORIA
Mailing Address - State:IL
Mailing Address - Zip Code:61637-0001
Mailing Address - Country:US
Mailing Address - Phone:309-655-2000
Mailing Address - Fax:309-655-7869
Practice Address - Street 1:100 NE RANDOLPH AVE
Practice Address - Street 2:
Practice Address - City:PEORIA
Practice Address - State:IL
Practice Address - Zip Code:61606-1919
Practice Address - Country:US
Practice Address - Phone:309-624-8575
Practice Address - Fax:309-624-8566
Is Sole Proprietor?:No
Enumeration Date:2006-07-31
Last Update Date:2009-07-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL070-013748225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist