Provider Demographics
NPI:1497045405
Name:SUTKOWSKI, SALLY (R, PT)
Entity Type:Individual
Prefix:
First Name:SALLY
Middle Name:
Last Name:SUTKOWSKI
Suffix:
Gender:F
Credentials:R, PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4755 N GRANDVIEW DR
Mailing Address - Street 2:
Mailing Address - City:PEORIA
Mailing Address - State:IL
Mailing Address - Zip Code:61616-5418
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:5401 N KNOXVILLE AVE
Practice Address - Street 2:SUITE 117
Practice Address - City:PEORIA
Practice Address - State:IL
Practice Address - Zip Code:61614-5098
Practice Address - Country:US
Practice Address - Phone:309-671-8749
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-04-11
Last Update Date:2011-10-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL070000502225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL070000502OtherLICENSE
IL216706OtherGROUP PTAN
IL070000502OtherLICENSE
IL216706OtherGROUP PTAN