Provider Demographics
NPI:1639486657
Name:BALLENGER, KRISTIN ROSE (DPT)
Entity Type:Individual
Prefix:
First Name:KRISTIN
Middle Name:ROSE
Last Name:BALLENGER
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5545 W MONTROSE AVE
Mailing Address - Street 2:SUITE 1100
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60641-1331
Mailing Address - Country:US
Mailing Address - Phone:773-282-6648
Mailing Address - Fax:
Practice Address - Street 1:20 S CLARK ST
Practice Address - Street 2:SUITE 1100
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60603-1802
Practice Address - Country:US
Practice Address - Phone:312-368-8400
Practice Address - Fax:312-368-8450
Is Sole Proprietor?:No
Enumeration Date:2010-09-13
Last Update Date:2016-08-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL070017339225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist