Provider Demographics
NPI:1952556615
Name:MINNICH-MEYER, KATHRYN ANN (PTA)
Entity Type:Individual
Prefix:
First Name:KATHRYN
Middle Name:ANN
Last Name:MINNICH-MEYER
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:KATHRYN
Other - Middle Name:A
Other - Last Name:MINNICH
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PTA
Mailing Address - Street 1:3815 EAST MAIN STREET
Mailing Address - Street 2:SUITE B
Mailing Address - City:ST CHARLES
Mailing Address - State:IL
Mailing Address - Zip Code:60174
Mailing Address - Country:US
Mailing Address - Phone:708-307-9136
Mailing Address - Fax:
Practice Address - Street 1:3815 EAST MAIN ST.
Practice Address - Street 2:
Practice Address - City:ST. CHARLES
Practice Address - State:IL
Practice Address - Zip Code:60174
Practice Address - Country:US
Practice Address - Phone:630-584-7530
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-11-22
Last Update Date:2015-02-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL160001657225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant