Healthcare Provider Details

I. General information

NPI: 1639800683
Provider Name (Legal Business Name): KATHERINE KLOCEK
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/21/2022
Last Update Date: 06/21/2022
Certification Date: 06/21/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1601 BUTTERFIELD TRL
KANKAKEE IL
60901-2959
US

IV. Provider business mailing address

480 PLUM CREEK CT APT 1
BOURBONNAIS IL
60914-1582
US

V. Phone/Fax

Practice location:
  • Phone: 815-342-2507
  • Fax:
Mailing address:
  • Phone: 815-342-2508
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License Number0040659
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: