Healthcare Provider Details

I. General information

NPI: 1912358847
Provider Name (Legal Business Name): KEVIN LAUDNER PHD, ATC
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/22/2016
Last Update Date: 06/22/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

ILLINOIS STATE UNIVERSITY CAMPUS BOX 5000
NORMAL IL
61709-5000
US

IV. Provider business mailing address

ILLINOIS STATE UNIVERSITY CAMPUS BOX 5000
NORMAL IL
61709-5000
US

V. Phone/Fax

Practice location:
  • Phone: 309-438-7609
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code226300000X
TaxonomyKinesiotherapist
License Number096001304
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: