Provider Demographics
NPI:1679679187
Name:HARRISON, KRISTOPHER D (PHYSICAL THERAPY)
Entity Type:Individual
Prefix:MR
First Name:KRISTOPHER
Middle Name:D
Last Name:HARRISON
Suffix:
Gender:M
Credentials:PHYSICAL THERAPY
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:790 REMINGTON BLVD
Mailing Address - Street 2:
Mailing Address - City:BOLINGBROOK
Mailing Address - State:IL
Mailing Address - Zip Code:60440-4909
Mailing Address - Country:US
Mailing Address - Phone:630-296-2222
Mailing Address - Fax:630-759-9510
Practice Address - Street 1:2595 E DIVISION ST
Practice Address - Street 2:
Practice Address - City:DIAMOND
Practice Address - State:IL
Practice Address - Zip Code:60416-9794
Practice Address - Country:US
Practice Address - Phone:815-634-8420
Practice Address - Fax:815-634-8430
Is Sole Proprietor?:No
Enumeration Date:2006-09-15
Last Update Date:2016-11-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL070013745225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILK04677Medicare ID - Type Unspecified