Provider Demographics
NPI:1851009005
Name:KOVAR, LAURYN LYNN (PTA)
Entity Type:Individual
Prefix:
First Name:LAURYN
Middle Name:LYNN
Last Name:KOVAR
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 1:1705 MITCHELL AVE
Mailing Address - Street 2:
Mailing Address - City:GRANITE CITY
Mailing Address - State:IL
Mailing Address - Zip Code:62040-2324
Mailing Address - Country:US
Mailing Address - Phone:618-946-8909
Mailing Address - Fax:
Practice Address - Street 1:27 AUERBACH PL
Practice Address - Street 2:
Practice Address - City:GLEN CARBON
Practice Address - State:IL
Practice Address - Zip Code:62034-1596
Practice Address - Country:US
Practice Address - Phone:618-946-8909
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-11-07
Last Update Date:2022-11-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL160009652225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant