MEDICARE: CARRIE KOOYENGA PTA

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	225200000X	Physical Therapy Assistant	160.005053	IL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	160.005053	OTHER	IL	STATE OF ILLINOIS LICENSE

General Provider Information

NPI Number	:	1942450515
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	CARRIE KOOYENGA PTA

Provider Business Mailing Address
First Line	:	10100 FOREST HILLS RD
Second Line	:
City	:	MACHESNEY PARK
State	:	IL
Zip	:	61115-8234
Country	:	US
Telephone Number	:	815-713-2742
Fax Number	:	815-282-8597

Provider Business Practice Location Address
First Line	:	1663 BELVIDERE RD
Second Line	:
City	:	BELVIDERE
State	:	IL
Zip	:	61008-9306
Country	:	US
Telephone Number	:	815-544-0040
Fax Number	:	815-544-0048

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	09/19/2008
Last Update Date	:	09/19/2008

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Directions to “ CARRIE KOOYENGA PTA” Practice Location

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