Provider Demographics
NPI:1871012443
Name:CO, TIMOTHY
Entity Type:Individual
Prefix:
First Name:TIMOTHY
Middle Name:
Last Name:CO
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1288 PERRY ST APT 11
Mailing Address - Street 2:
Mailing Address - City:DES PLAINES
Mailing Address - State:IL
Mailing Address - Zip Code:60016-3359
Mailing Address - Country:US
Mailing Address - Phone:847-644-9714
Mailing Address - Fax:
Practice Address - Street 1:401 W LAKE ST
Practice Address - Street 2:
Practice Address - City:NORTHLAKE
Practice Address - State:IL
Practice Address - Zip Code:60164-2435
Practice Address - Country:US
Practice Address - Phone:847-644-9714
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-09-15
Last Update Date:2019-01-16
Deactivation Date:2018-10-11
Deactivation Code:
Reactivation Date:2019-01-16
Provider Licenses
StateLicense IDTaxonomies
IL160007830225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant