Provider Demographics
NPI:1407430580
Name:KNOEBEL, CAITLYN EREN
Entity Type:Individual
Prefix:
First Name:CAITLYN
Middle Name:EREN
Last Name:KNOEBEL
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 1:6637 LIEBIG SCHOOL RD
Mailing Address - Street 2:
Mailing Address - City:MASCOUTAH
Mailing Address - State:IL
Mailing Address - Zip Code:62258-4033
Mailing Address - Country:US
Mailing Address - Phone:618-920-5112
Mailing Address - Fax:
Practice Address - Street 1:201 S 10TH ST
Practice Address - Street 2:
Practice Address - City:MASCOUTAH
Practice Address - State:IL
Practice Address - Zip Code:62258-1736
Practice Address - Country:US
Practice Address - Phone:618-566-8000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-05-05
Last Update Date:2021-05-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL160.008190225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant