Provider Demographics
NPI:1750458394
Name:ILLIG, KATHLEEN ANN (PTA)
Entity Type:Individual
Prefix:MRS
First Name:KATHLEEN
Middle Name:ANN
Last Name:ILLIG
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 1:6655 QUINCE RD STE 101
Mailing Address - Street 2:
Mailing Address - City:MEMPHIS
Mailing Address - State:TN
Mailing Address - Zip Code:38119-8031
Mailing Address - Country:US
Mailing Address - Phone:901-755-9988
Mailing Address - Fax:901-755-2233
Practice Address - Street 1:6655 QUINCE RD STE 101
Practice Address - Street 2:
Practice Address - City:MEMPHIS
Practice Address - State:TN
Practice Address - Zip Code:38119-8031
Practice Address - Country:US
Practice Address - Phone:901-755-9988
Practice Address - Fax:901-755-2233
Is Sole Proprietor?:No
Enumeration Date:2006-11-29
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNPTA 0000003466225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3077388OtherBCBS PROVIDER NUMBER
TN446569Medicare ID - Type UnspecifiedMEDICARE PROVIDER NUMBER