Provider Demographics
NPI:1548996002
Name:KEISTER, MICHAELA LEE (DPT)
Entity type:Individual
Prefix:
First Name:MICHAELA
Middle Name:LEE
Last Name:KEISTER
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:MICHAELA
Other - Middle Name:LEE
Other - Last Name:NELSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DPT
Mailing Address - Street 1:6707 SALADINO DR
Mailing Address - Street 2:
Mailing Address - City:ROSCOE
Mailing Address - State:IL
Mailing Address - Zip Code:61073-9210
Mailing Address - Country:US
Mailing Address - Phone:815-494-3608
Mailing Address - Fax:
Practice Address - Street 1:209 9TH ST
Practice Address - Street 2:
Practice Address - City:ROCKFORD
Practice Address - State:IL
Practice Address - Zip Code:61104-2235
Practice Address - Country:US
Practice Address - Phone:779-696-8318
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-07-27
Last Update Date:2023-06-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL070.026695225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist