Healthcare Provider Details

I. General information

NPI: 1316573447
Provider Name (Legal Business Name): KRYSTAL KOTECKI
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/20/2020
Last Update Date: 03/20/2020
Certification Date: 03/20/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1230 N HIGHLAND AVE
AURORA IL
60506-1401
US

IV. Provider business mailing address

1230 N HIGHLAND AVE
AURORA IL
60506-1401
US

V. Phone/Fax

Practice location:
  • Phone: 630-966-4300
  • Fax:
Mailing address:
  • Phone: 630-966-4300
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: