Healthcare Provider Details

I. General information

NPI: 1700397064
Provider Name (Legal Business Name): KELLY STEVENS PT, DPT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/13/2017
Last Update Date: 11/20/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2845 N SHERIDAN RD SUITE 6400
CHICAGO IL
60657
US

IV. Provider business mailing address

1000 REMINGTON BLVD STE 100
BOLINGBROOK IL
60440-4707
US

V. Phone/Fax

Practice location:
  • Phone: 773-665-8400
  • Fax:
Mailing address:
  • Phone: 630-914-2898
  • Fax: 630-914-2469

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number070023222
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: