Provider Demographics
NPI:1609103787
Name:ALLEN-WACKER, KATIE E (PTA)
Entity Type:Individual
Prefix:MRS
First Name:KATIE
Middle Name:E
Last Name:ALLEN-WACKER
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1534
Mailing Address - Street 2:
Mailing Address - City:BELVIDERE
Mailing Address - State:IL
Mailing Address - Zip Code:61008-1705
Mailing Address - Country:US
Mailing Address - Phone:815-568-8878
Mailing Address - Fax:815-568-9977
Practice Address - Street 1:212 LINDOW LANE
Practice Address - Street 2:SUITE M
Practice Address - City:MARENGO
Practice Address - State:IL
Practice Address - Zip Code:60152
Practice Address - Country:US
Practice Address - Phone:815-568-8878
Practice Address - Fax:815-568-9977
Is Sole Proprietor?:No
Enumeration Date:2009-11-10
Last Update Date:2009-11-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL160005283225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant