Provider Demographics
NPI:1144846114
Name:STEFANOV, NIKITA (PT)
Entity type:Individual
Prefix:
First Name:NIKITA
Middle Name:
Last Name:STEFANOV
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 1:150 RED TOP DR APT 203
Mailing Address - Street 2:
Mailing Address - City:LIBERTYVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:60048-5237
Mailing Address - Country:US
Mailing Address - Phone:773-575-1848
Mailing Address - Fax:
Practice Address - Street 1:701 N MILWAUKEE AVE STE 246B
Practice Address - Street 2:
Practice Address - City:VERNON HILLS
Practice Address - State:IL
Practice Address - Zip Code:60061-1524
Practice Address - Country:US
Practice Address - Phone:773-796-3069
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-06-24
Last Update Date:2023-07-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL070.025197225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist