Healthcare Provider Details

I. General information

NPI: 1053769760
Provider Name (Legal Business Name): CODY HUTCHINSON PTA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/03/2016
Last Update Date: 06/03/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2943 W JEFFERSON ST
JOLIET IL
60435
US

IV. Provider business mailing address

1000 BURR RIDGE PKWY SUITE 200
BURR RIDGE IL
60527-0849
US

V. Phone/Fax

Practice location:
  • Phone: 630-920-4670
  • Fax: 630-920-4687
Mailing address:
  • Phone: 630-920-4670
  • Fax: 630-920-4687

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License Number160.006898
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: