Provider Demographics
NPI:1902973951
Name:DECANT, KRISTINE SUE (DPT, NCS)
Entity Type:Individual
Prefix:DR
First Name:KRISTINE
Middle Name:SUE
Last Name:DECANT
Suffix:
Gender:F
Credentials:DPT, NCS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:29373 NETWORK PL
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60673-1293
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:695 PARK AVE
Practice Address - Street 2:
Practice Address - City:LAKE VILLA
Practice Address - State:IL
Practice Address - Zip Code:60046-6531
Practice Address - Country:US
Practice Address - Phone:224-541-9100
Practice Address - Fax:224-541-9070
Is Sole Proprietor?:No
Enumeration Date:2006-11-28
Last Update Date:2023-03-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL0700178442251N0400X, 225100000X
WI126652251N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
No2251N0400XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistNeurology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL59724004OtherMEDICARE PTAN
IL070017844OtherIL-LICENSE