=====================================================
General NPI Number Information
=====================================================
NPI Number | 1285435172
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | HEATHER KODER PTA
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/24/2025
-----------------------------------------------------
Last Update Date | 03/24/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | USS TRANQUILITY 3410 ILLINOIS ST
-----------------------------------------------------
City | GREAT LAKES
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60088
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 224-392-6914
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3852 N PONTIAC AVE
-----------------------------------------------------
City | CHICAGO
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60634-1929
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 246Z00000X
-----------------------------------------------------
Taxonomy Name | Other Specialist/Technologist
-----------------------------------------------------
License Number | 160.009101
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------