Provider Demographics
NPI:1902883069
Name:NISIUS, KATHLEEN (PT)
Entity Type:Individual
Prefix:
First Name:KATHLEEN
Middle Name:
Last Name:NISIUS
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:KATHLEEN
Other - Middle Name:
Other - Last Name:LAGRASSA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PT
Mailing Address - Street 1:7825 3RD ST N
Mailing Address - Street 2:STE 105
Mailing Address - City:OAKDALE
Mailing Address - State:MN
Mailing Address - Zip Code:55128-5444
Mailing Address - Country:US
Mailing Address - Phone:877-609-0123
Mailing Address - Fax:888-425-0398
Practice Address - Street 1:11613 CATALPA LN
Practice Address - Street 2:
Practice Address - City:WOODSTOCK
Practice Address - State:IL
Practice Address - Zip Code:60098-6923
Practice Address - Country:US
Practice Address - Phone:877-609-0123
Practice Address - Fax:888-425-0398
Is Sole Proprietor?:No
Enumeration Date:2005-12-29
Last Update Date:2021-08-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL070-011947225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILK22582Medicare ID - Type Unspecified