Provider Demographics
NPI:1265765937
Name:HOOTMAN, KEALY A (LPT)
Entity type:Individual
Prefix:
First Name:KEALY
Middle Name:A
Last Name:HOOTMAN
Suffix:
Gender:F
Credentials:LPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5100 E STATE ST
Mailing Address - Street 2:STE 200
Mailing Address - City:ROCKFORD
Mailing Address - State:IL
Mailing Address - Zip Code:61108-2913
Mailing Address - Country:US
Mailing Address - Phone:815-637-2200
Mailing Address - Fax:815-637-2900
Practice Address - Street 1:5100 E STATE ST
Practice Address - Street 2:STE 200
Practice Address - City:ROCKFORD
Practice Address - State:IL
Practice Address - Zip Code:61108-2913
Practice Address - Country:US
Practice Address - Phone:815-637-2200
Practice Address - Fax:815-637-2900
Is Sole Proprietor?:No
Enumeration Date:2009-09-14
Last Update Date:2009-09-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL070014723225XP0019X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225XP0019XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistPhysical Rehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL070014723OtherLICENSED PHYSICAL THERAPIST