MEDICARE: MRS. CORISSA JEAN KEEFNER PT, DPT

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	225100000X	Physical Therapist	070-012968	IL

General Provider Information

NPI Number	:	1558300129
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. CORISSA JEAN KEEFNER PT, DPT

Provider Business Mailing Address
First Line	:	4007 N KENMORE AVE
Second Line	:	APT 1
City	:	CHICAGO
State	:	IL
Zip	:	60613-2092
Country	:	US
Telephone Number	:	773-458-3835
Fax Number	:

Provider Business Practice Location Address
First Line	:	4007 N KENMORE AVE
Second Line	:	APT 1
City	:	CHICAGO
State	:	IL
Zip	:	60613-2092
Country	:	US
Telephone Number	:	773-458-3835
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/06/2006
Last Update Date	:	03/03/2020

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