Healthcare Provider Details

I. General information

NPI: 1174647069
Provider Name (Legal Business Name): KARA BOYNEWICZ PT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/18/2007
Last Update Date: 07/11/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3721 N RICHMOND ST
CHICAGO IL
60618-3524
US

IV. Provider business mailing address

3721 N RICHMOND ST
CHICAGO IL
60618-3524
US

V. Phone/Fax

Practice location:
  • Phone: 773-478-9245
  • Fax: 435-578-8231
Mailing address:
  • Phone: 773-478-9245
  • Fax: 435-578-8231

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number070.012672
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code252Y00000X
TaxonomyEarly Intervention Provider Agency
License Number070012672
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: