Provider Demographics
NPI:1053543041
Name:KANTEN, WYNN E (PT)
Entity type:Individual
Prefix:
First Name:WYNN
Middle Name:E
Last Name:KANTEN
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:22703 LAWNDALE AVE
Mailing Address - Street 2:
Mailing Address - City:RICHTON PARK
Mailing Address - State:IL
Mailing Address - Zip Code:60471-2540
Mailing Address - Country:US
Mailing Address - Phone:708-503-1951
Mailing Address - Fax:708-248-7771
Practice Address - Street 1:421 DORIS AVE
Practice Address - Street 2:
Practice Address - City:JOLIET
Practice Address - State:IL
Practice Address - Zip Code:60433-2569
Practice Address - Country:US
Practice Address - Phone:815-727-8776
Practice Address - Fax:815-727-8775
Is Sole Proprietor?:Yes
Enumeration Date:2009-08-10
Last Update Date:2009-08-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL070.005101225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL070.005101OtherSTATE LICENSURE