Healthcare Provider Details

I. General information

NPI: 1396517934
Provider Name (Legal Business Name): JOSHUA KUTCHMA PT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/26/2023
Last Update Date: 10/26/2023
Certification Date: 10/05/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

228 ALTON SQ STE H1
ALTON IL
62002-5919
US

IV. Provider business mailing address

228 ALTON SQ STE H1
ALTON IL
62002-5919
US

V. Phone/Fax

Practice location:
  • Phone: 618-463-5171
  • Fax: 618-463-5175
Mailing address:
  • Phone: 618-463-5171
  • Fax: 618-463-5175

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number070.027834
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: