Provider Demographics
NPI:1407399165
Name:CHALKE, KOURTNEY (COTA/L)
Entity Type:Individual
Prefix:
First Name:KOURTNEY
Middle Name:
Last Name:CHALKE
Suffix:
Gender:F
Credentials:COTA/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:129 N SYCAMORE ST
Mailing Address - Street 2:
Mailing Address - City:CENTRALIA
Mailing Address - State:IL
Mailing Address - Zip Code:62801-3236
Mailing Address - Country:US
Mailing Address - Phone:618-335-4803
Mailing Address - Fax:
Practice Address - Street 1:129 N SYCAMORE ST
Practice Address - Street 2:
Practice Address - City:CENTRALIA
Practice Address - State:IL
Practice Address - Zip Code:62801-3236
Practice Address - Country:US
Practice Address - Phone:618-335-4803
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-11-29
Last Update Date:2016-11-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL057.004644224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant