Provider Demographics
NPI:1821270331
Name:BOEHMER, KATHLEEN M (PTA)
Entity Type:Individual
Prefix:
First Name:KATHLEEN
Middle Name:M
Last Name:BOEHMER
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 1:319 FRONT ST
Mailing Address - Street 2:
Mailing Address - City:MCHENRY
Mailing Address - State:IL
Mailing Address - Zip Code:60050-5504
Mailing Address - Country:US
Mailing Address - Phone:815-578-9655
Mailing Address - Fax:815-578-9642
Practice Address - Street 1:319 FRONT ST
Practice Address - Street 2:
Practice Address - City:MCHENRY
Practice Address - State:IL
Practice Address - Zip Code:60050-5504
Practice Address - Country:US
Practice Address - Phone:815-578-9655
Practice Address - Fax:815-578-9642
Is Sole Proprietor?:No
Enumeration Date:2007-11-27
Last Update Date:2007-11-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL05632057OtherBLUE CROSS BLUE SHIELD
IL7515430OtherAETNA