Provider Demographics
NPI:1760656763
Name:BROWN, KATHLEEN SUE (PTA)
Entity Type:Individual
Prefix:MRS
First Name:KATHLEEN
Middle Name:SUE
Last Name:BROWN
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:MRS
Other - First Name:KATHLEEN
Other - Middle Name:SUE
Other - Last Name:LEARNED
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PTA
Mailing Address - Street 1:6501 N SHERIDAN RD
Mailing Address - Street 2:
Mailing Address - City:PEORIA
Mailing Address - State:IL
Mailing Address - Zip Code:61614-2932
Mailing Address - Country:US
Mailing Address - Phone:309-671-2950
Mailing Address - Fax:
Practice Address - Street 1:6501 N SHERIDAN RD
Practice Address - Street 2:
Practice Address - City:PEORIA
Practice Address - State:IL
Practice Address - Zip Code:61614-2932
Practice Address - Country:US
Practice Address - Phone:309-671-2950
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-04-22
Last Update Date:2008-04-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL160.002222225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant