Provider Demographics
NPI:1053886796
Name:KOOIKER, ERIN NICOLE (PTA)
Entity type:Individual
Prefix:
First Name:ERIN
Middle Name:NICOLE
Last Name:KOOIKER
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:17137 CENTRAL AVE
Mailing Address - Street 2:
Mailing Address - City:TINLEY PARK
Mailing Address - State:IL
Mailing Address - Zip Code:60477-3022
Mailing Address - Country:US
Mailing Address - Phone:708-712-3450
Mailing Address - Fax:
Practice Address - Street 1:811 W EVERGREEN AVE
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60642-2682
Practice Address - Country:US
Practice Address - Phone:312-242-1665
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-10-09
Last Update Date:2018-10-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL160007879225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant