Provider Demographics
NPI:1669129136
Name:FORTMAN, KATIE ROSE (DC)
Entity type:Individual
Prefix:DR
First Name:KATIE
Middle Name:ROSE
Last Name:FORTMAN
Suffix:
Gender:F
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1111 W 14TH PL UNIT 109
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60608-2796
Mailing Address - Country:US
Mailing Address - Phone:708-945-8437
Mailing Address - Fax:
Practice Address - Street 1:600 W CHICAGO AVE STE 1000
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60654-2801
Practice Address - Country:US
Practice Address - Phone:312-625-0845
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-03-04
Last Update Date:2024-02-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL038013753111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor