Provider Demographics
NPI:1598094245
Name:MEDINA, KATHRYN (DPT)
Entity Type:Individual
Prefix:
First Name:KATHRYN
Middle Name:
Last Name:MEDINA
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:KATHRYN
Other - Middle Name:
Other - Last Name:NICHOLSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DPT
Mailing Address - Street 1:852 MADISON ST
Mailing Address - Street 2:
Mailing Address - City:OAK PARK
Mailing Address - State:IL
Mailing Address - Zip Code:60302-4441
Mailing Address - Country:US
Mailing Address - Phone:708-445-3965
Mailing Address - Fax:708-445-1355
Practice Address - Street 1:852 MADISON ST
Practice Address - Street 2:
Practice Address - City:OAK PARK
Practice Address - State:IL
Practice Address - Zip Code:60302-4441
Practice Address - Country:US
Practice Address - Phone:708-445-3965
Practice Address - Fax:708-445-1355
Is Sole Proprietor?:No
Enumeration Date:2009-12-09
Last Update Date:2016-11-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL070016481225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
P01369260Medicare PIN
F400143345Medicare PIN
IL211585018Medicare PIN