Provider Demographics
NPI:1679098420
Name:KINGERY, SIDNEY M (PT, DPT)
Entity type:Individual
Prefix:
First Name:SIDNEY
Middle Name:M
Last Name:KINGERY
Suffix:
Gender:F
Credentials:PT, DPT
Other - Prefix:
Other - First Name:SIDNEY
Other - Middle Name:M
Other - Last Name:KANE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DPT
Mailing Address - Street 1:600 OAKMONT LN STE 600C
Mailing Address - Street 2:
Mailing Address - City:WESTMONT
Mailing Address - State:IL
Mailing Address - Zip Code:60559-5548
Mailing Address - Country:US
Mailing Address - Phone:630-575-6200
Mailing Address - Fax:
Practice Address - Street 1:5810 W PEORIA AVE
Practice Address - Street 2:
Practice Address - City:GLENDALE
Practice Address - State:AZ
Practice Address - Zip Code:85302
Practice Address - Country:US
Practice Address - Phone:623-219-4242
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-08-12
Last Update Date:2018-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL070022931225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist