Provider Demographics
NPI:1730467986
Name:HOLTGRAVE, KAITLIN MARY (PT)
Entity Type:Individual
Prefix:
First Name:KAITLIN
Middle Name:MARY
Last Name:HOLTGRAVE
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:225 E CHICAGO AVE # 142
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60611-2991
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:312-227-9425
Practice Address - Street 1:225 E CHICAGO AVE # 142
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60611-2991
Practice Address - Country:US
Practice Address - Phone:312-227-6240
Practice Address - Fax:312-227-9425
Is Sole Proprietor?:No
Enumeration Date:2011-07-21
Last Update Date:2016-12-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL070018480225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist