Healthcare Provider Details

I. General information

NPI: 1255083176
Provider Name (Legal Business Name): ROLA KERSHA DPT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/21/2022
Last Update Date: 01/21/2022
Certification Date: 01/21/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8434 CORCORAN RD
WILLOW SPRINGS IL
60480-1666
US

IV. Provider business mailing address

3524 STACKINGHAY DR
NAPERVILLE IL
60564-8336
US

V. Phone/Fax

Practice location:
  • Phone: 708-467-0657
  • Fax:
Mailing address:
  • Phone: 248-496-9924
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number070.026264
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: