Healthcare Provider Details

I. General information

NPI: 1184607889
Provider Name (Legal Business Name): AMY NOVAK ATC, CSCS
Entity Type: Individual
Gender: Female
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 11/28/2005
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6255 S ARCHER AVE
CHICAGO IL
60638-2609
US

IV. Provider business mailing address

15411 AUBRIETA CT
ORLAND PARK IL
60462-4315
US

V. Phone/Fax

Practice location:
  • Phone: 773-284-6735
  • Fax:
Mailing address:
  • Phone: 708-250-8458
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: