Healthcare Provider Details

I. General information

NPI: 1275860694
Provider Name (Legal Business Name): COLLEEN SKOTNICKI PT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/05/2009
Last Update Date: 12/21/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

23408 W APOLLO CT
LAKE VILLA IL
60046-9638
US

IV. Provider business mailing address

1250 GOLDFINCH LN
ANTIOCH IL
60002-6410
US

V. Phone/Fax

Practice location:
  • Phone: 847-856-9014
  • Fax:
Mailing address:
  • Phone: 847-977-7188
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number070013436
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: