Provider Demographics
NPI:1851611255
Name:NIEWOHNER, KRAIG (PTA)
Entity Type:Individual
Prefix:
First Name:KRAIG
Middle Name:
Last Name:NIEWOHNER
Suffix:
Gender:M
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:550 FRONTAGE RD
Mailing Address - Street 2:SUITE 2415
Mailing Address - City:NORTHFIELD
Mailing Address - State:IL
Mailing Address - Zip Code:60093-1202
Mailing Address - Country:US
Mailing Address - Phone:847-441-5593
Mailing Address - Fax:847-441-0734
Practice Address - Street 1:435 CAMDEN RD
Practice Address - Street 2:
Practice Address - City:MOUNT STERLING
Practice Address - State:IL
Practice Address - Zip Code:62353-1058
Practice Address - Country:US
Practice Address - Phone:217-773-3377
Practice Address - Fax:217-773-3255
Is Sole Proprietor?:Yes
Enumeration Date:2010-06-08
Last Update Date:2010-06-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL160.004062225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant