Provider Demographics
NPI:1669701553
Name:BANAS, KRISTINE MAE MARTINEZ (RPT)
Entity type:Individual
Prefix:
First Name:KRISTINE MAE
Middle Name:MARTINEZ
Last Name:BANAS
Suffix:
Gender:F
Credentials:RPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4945 N NAGLE AVE
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60630-2927
Mailing Address - Country:US
Mailing Address - Phone:773-681-6142
Mailing Address - Fax:
Practice Address - Street 1:10700 W HIGGINS RD
Practice Address - Street 2:SUITE 120
Practice Address - City:ROSEMONT
Practice Address - State:IL
Practice Address - Zip Code:60018-3707
Practice Address - Country:US
Practice Address - Phone:847-299-2801
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-12-23
Last Update Date:2009-12-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL070.017019225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist