Healthcare Provider Details

I. General information

NPI: 1114693660
Provider Name (Legal Business Name): EMILY KOCANDA PT, DPT, LMT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/16/2021
Last Update Date: 08/16/2021
Certification Date: 08/10/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

611 ROCKLAND RD STE 105
LAKE BLUFF IL
60044-2000
US

IV. Provider business mailing address

611 ROCKLAND RD STE 102
LAKE BLUFF IL
60044-2000
US

V. Phone/Fax

Practice location:
  • Phone: 847-234-4847
  • Fax: 847-234-4850
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code225700000X
TaxonomyMassage Therapist
License Number227013152
License Number StateIL
# 2
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number070023032
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: