Healthcare Provider Details

I. General information

NPI: 1356144117
Provider Name (Legal Business Name): KEVIN MATTHEW POCZTOWSKI PTA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/28/2025
Last Update Date: 03/28/2025
Certification Date: 03/28/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1554 E ALGONQUIN RD
ALGONQUIN IL
60102-4519
US

IV. Provider business mailing address

502 OLD COUNTRY WAY
WAUCONDA IL
60084-1790
US

V. Phone/Fax

Practice location:
  • Phone: 224-592-1221
  • Fax:
Mailing address:
  • Phone: 847-970-2664
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License Number160.010369
License Number StateIL

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: