MEDICARE: OUTLIER PHYSICAL THERAPY, LLC

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	070022565	IL

General Provider Information

NPI Number	:	1720594484
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	OUTLIER PHYSICAL THERAPY, LLC

Provider Business Mailing Address
First Line	:	1781 TUDOR LN UNIT 306
Second Line	:
City	:	NORTHBROOK
State	:	IL
Zip	:	60062-3780
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	1781 SAINT JOHNS AVE
Second Line	:
City	:	HIGHLAND PARK
State	:	IL
Zip	:	60035-3532
Country	:	US
Telephone Number	:	847-452-4066
Fax Number	:

Authorized Official
Title or Position	:	PHYSICAL THERAPIST, OWNER
Name	:	DR. KATHLEEN BLANKSHAIN
Credential	:	PT, DPT
Telephone Number	:	847-452-4066

Provider Enumeration Date	:	12/18/2017
Last Update Date	:	11/15/2022

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