Provider Demographics
NPI:1841934916
Name:COSTEN, JAMES CLARK (PT)
Entity type:Individual
Prefix:
First Name:JAMES
Middle Name:CLARK
Last Name:COSTEN
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:111 N WABASH AVE STE 2109
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60602-2935
Mailing Address - Country:US
Mailing Address - Phone:312-368-4344
Mailing Address - Fax:
Practice Address - Street 1:111 N WABASH AVE STE 2109
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60602-2935
Practice Address - Country:US
Practice Address - Phone:312-368-4344
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-04-25
Last Update Date:2022-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL070011386225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist