Healthcare Provider Details

I. General information

NPI: 1104886464
Provider Name (Legal Business Name): KRISTIE JO HITTLE MA, ATC, LAT
Entity Type: Individual
Gender: Female
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 03/23/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7400 AUGUSTA ST
RIVER FOREST IL
60305-1402
US

IV. Provider business mailing address

911 S COUNTRY LN
MT PROSPECT IL
60056-4234
US

V. Phone/Fax

Practice location:
  • Phone: 708-209-3620
  • Fax: 708-209-3154
Mailing address:
  • Phone: 989-666-8919
  • Fax: 708-209-3154

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License Number
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: