Provider Demographics
NPI:1376943639
Name:KOSTIV, TETYANA
Entity Type:Individual
Prefix:
First Name:TETYANA
Middle Name:
Last Name:KOSTIV
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:300 ANTHONY AVE UNIT 202
Mailing Address - Street 2:
Mailing Address - City:MUNDELEIN
Mailing Address - State:IL
Mailing Address - Zip Code:60060-2451
Mailing Address - Country:US
Mailing Address - Phone:224-628-0189
Mailing Address - Fax:
Practice Address - Street 1:300 ANTHONY AVE UNIT 202
Practice Address - Street 2:
Practice Address - City:MUNDELEIN
Practice Address - State:IL
Practice Address - Zip Code:60060-2451
Practice Address - Country:US
Practice Address - Phone:224-628-0189
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-08-23
Last Update Date:2014-08-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL227.001585111NX0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111NX0100XChiropractic ProvidersChiropractorOccupational Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL227.001585OtherLICENSED MASSAGE THERAPIST