Healthcare Provider Details

I. General information

NPI: 1013474402
Provider Name (Legal Business Name): KRISTIN UPP PTA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/21/2019
Last Update Date: 02/21/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

333 MADISON ST
JOLIET IL
60435-8200
US

IV. Provider business mailing address

5304 WHISPERING OAKS DR
PLAINFIELD IL
60586-6633
US

V. Phone/Fax

Practice location:
  • Phone: 815-725-7133
  • Fax:
Mailing address:
  • Phone: 630-632-8921
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License Number160.003981
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: