Healthcare Provider Details

I. General information

NPI: 1144530981
Provider Name (Legal Business Name): AMANDA K KOCIS DPT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/14/2010
Last Update Date: 06/14/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 PINE TREE CT
KEWANEE IL
61443-9600
US

IV. Provider business mailing address

1051 W SOUTH ST PO BOX 747
KEWANEE IL
61443-8354
US

V. Phone/Fax

Practice location:
  • Phone: 309-540-9895
  • Fax:
Mailing address:
  • Phone: 309-852-7500
  • Fax: 309-852-7948

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number070-014532
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: