Provider Demographics
NPI:1467562660
Name:PETERSON, KRISTEN (PT)
Entity Type:Individual
Prefix:
First Name:KRISTEN
Middle Name:
Last Name:PETERSON
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:600 OAKMONT LN STE 600C
Mailing Address - Street 2:
Mailing Address - City:WESTMONT
Mailing Address - State:IL
Mailing Address - Zip Code:60559-5548
Mailing Address - Country:US
Mailing Address - Phone:630-575-6200
Mailing Address - Fax:
Practice Address - Street 1:3865 E MAIN ST
Practice Address - Street 2:
Practice Address - City:ST CHARLES
Practice Address - State:IL
Practice Address - Zip Code:60174-2424
Practice Address - Country:US
Practice Address - Phone:630-587-5788
Practice Address - Fax:630-588-7870
Is Sole Proprietor?:No
Enumeration Date:2006-08-30
Last Update Date:2018-04-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL070014135225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL1619908OtherBCBS IL GROUP NUMBER
IL567700OtherMEDICARE GROUP NUMBER
IL1623066OtherBCBS PROVIDER #
IL367885100OtherUS DEPT OF LABOR PROV.#
IL568080OtherMEDICARE GROUP NUMBER
IL568150OtherMEDICARE GROUP NUMBER
IL200852Medicare ID - Type UnspecifiedMEDICARE GROUP #
IL1619908OtherBCBS IL GROUP NUMBER
IL1623066OtherBCBS PROVIDER #
IL568150OtherMEDICARE GROUP NUMBER
ILK52174Medicare PIN