Provider Demographics
NPI:1942698295
Name:QUACKENBUSH, KATHLEEN TERESE
Entity Type:Individual
Prefix:MRS
First Name:KATHLEEN
Middle Name:TERESE
Last Name:QUACKENBUSH
Suffix:
Gender:F
Credentials:
Other - Prefix:MISS
Other - First Name:KATHLEEN
Other - Middle Name:TERESE
Other - Last Name:BAUMERT
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:2014 W 22ND PL
Mailing Address - Street 2:UNIT 1
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60608-4114
Mailing Address - Country:US
Mailing Address - Phone:630-429-6869
Mailing Address - Fax:
Practice Address - Street 1:2014 W 22ND PL
Practice Address - Street 2:UNIT 1
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60608-4114
Practice Address - Country:US
Practice Address - Phone:630-429-6869
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-01-08
Last Update Date:2015-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ILB56351887866222Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes222Q00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersDevelopmental Therapist