Provider Demographics
NPI:1144560699
Name:FITZGERALD, KATIE MICHELLE (PT)
Entity type:Individual
Prefix:
First Name:KATIE
Middle Name:MICHELLE
Last Name:FITZGERALD
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:790 REMINGTON BLVD
Mailing Address - Street 2:
Mailing Address - City:BOLINGBROOK
Mailing Address - State:IL
Mailing Address - Zip Code:60440-4909
Mailing Address - Country:US
Mailing Address - Phone:630-296-2223
Mailing Address - Fax:630-759-9510
Practice Address - Street 1:410 E CHURCH ST
Practice Address - Street 2:UNIT C
Practice Address - City:SANDWICH
Practice Address - State:IL
Practice Address - Zip Code:60548-2380
Practice Address - Country:US
Practice Address - Phone:815-786-3123
Practice Address - Fax:815-786-3136
Is Sole Proprietor?:Yes
Enumeration Date:2013-02-20
Last Update Date:2016-07-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL070017874225100000X
TX1222243225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist