Healthcare Provider Details

I. General information

NPI: 1427713163
Provider Name (Legal Business Name): AUSTIN HENKE
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/08/2021
Last Update Date: 11/08/2021
Certification Date: 11/08/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

852 MADISON ST
OAK PARK IL
60302-4441
US

IV. Provider business mailing address

852 MADISON ST
OAK PARK IL
60302-4441
US

V. Phone/Fax

Practice location:
  • Phone: 708-445-3965
  • Fax: 708-445-1355
Mailing address:
  • Phone: 708-445-3965
  • Fax: 708-445-1355

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number070026230
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: