Provider Demographics
NPI:1053036129
Name:KASICK, THERESA A
Entity type:Individual
Prefix:MRS
First Name:THERESA
Middle Name:A
Last Name:KASICK
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13020 S CENTRAL AVE
Mailing Address - Street 2:
Mailing Address - City:CRESTWOOD
Mailing Address - State:IL
Mailing Address - Zip Code:60418-2710
Mailing Address - Country:US
Mailing Address - Phone:708-389-0555
Mailing Address - Fax:
Practice Address - Street 1:13020 S CENTRAL AVE
Practice Address - Street 2:
Practice Address - City:CRESTWOOD
Practice Address - State:IL
Practice Address - Zip Code:60418-2710
Practice Address - Country:US
Practice Address - Phone:708-389-0555
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-10-11
Last Update Date:2022-10-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL160003471225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant