Healthcare Provider Details

I. General information

NPI: 1053886796
Provider Name (Legal Business Name): ERIN NICOLE KOOIKER PTA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/09/2018
Last Update Date: 10/09/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

811 W EVERGREEN AVE
CHICAGO IL
60642-2682
US

IV. Provider business mailing address

17137 CENTRAL AVE
TINLEY PARK IL
60477-3022
US

V. Phone/Fax

Practice location:
  • Phone: 312-242-1665
  • Fax:
Mailing address:
  • Phone: 708-712-3450
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License Number160007879
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: