Provider Demographics
NPI:1518403161
Name:KOORS, KATHLEEN
Entity Type:Individual
Prefix:
First Name:KATHLEEN
Middle Name:
Last Name:KOORS
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 1:6820 N IRON WOOD DR
Mailing Address - Street 2:
Mailing Address - City:EDWARDS
Mailing Address - State:IL
Mailing Address - Zip Code:61528-9421
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:530 NE GLEN OAK AVE
Practice Address - Street 2:
Practice Address - City:PEORIA
Practice Address - State:IL
Practice Address - Zip Code:61637-9421
Practice Address - Country:US
Practice Address - Phone:309-655-2381
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-01-06
Last Update Date:2017-01-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL070.015423225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist