Provider Demographics
NPI:1205062957
Name:MOUDRY, KATHERINE (DPT)
Entity type:Individual
Prefix:
First Name:KATHERINE
Middle Name:
Last Name:MOUDRY
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:KATHERINE
Other - Middle Name:
Other - Last Name:STANLEY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DPT
Mailing Address - Street 1:205 W WACKER DR
Mailing Address - Street 2:SUITE 1020
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60606-1216
Mailing Address - Country:US
Mailing Address - Phone:312-640-0329
Mailing Address - Fax:
Practice Address - Street 1:467 N WEBER RD
Practice Address - Street 2:
Practice Address - City:ROMEOVILLE
Practice Address - State:IL
Practice Address - Zip Code:60446-4144
Practice Address - Country:US
Practice Address - Phone:815-886-8771
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-06-09
Last Update Date:2013-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL070017125225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL146636Medicare UPIN