Provider Demographics
NPI:1932640646
Name:KIDD, KATELYN (PT)
Entity Type:Individual
Prefix:
First Name:KATELYN
Middle Name:
Last Name:KIDD
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1901 FRANK SCOTT PKWY E
Mailing Address - Street 2:
Mailing Address - City:SHILOH
Mailing Address - State:IL
Mailing Address - Zip Code:62269-7342
Mailing Address - Country:US
Mailing Address - Phone:618-235-0514
Mailing Address - Fax:618-235-0525
Practice Address - Street 1:1901 FRANK SCOTT PKWY E
Practice Address - Street 2:
Practice Address - City:SHILOH
Practice Address - State:IL
Practice Address - Zip Code:62269-7342
Practice Address - Country:US
Practice Address - Phone:618-235-0514
Practice Address - Fax:618-235-0525
Is Sole Proprietor?:No
Enumeration Date:2017-03-14
Last Update Date:2017-03-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL070.022804225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist