Provider Demographics
NPI:1174289938
Name:COUILLARD, KAITLYN ROSE (PTA)
Entity type:Individual
Prefix:
First Name:KAITLYN
Middle Name:ROSE
Last Name:COUILLARD
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:KAITLYN
Other - Middle Name:ROSE
Other - Last Name:THILL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PTA
Mailing Address - Street 1:PO BOX 735044
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60673-5044
Mailing Address - Country:US
Mailing Address - Phone:800-326-2250
Mailing Address - Fax:
Practice Address - Street 1:3117 SHORE DR
Practice Address - Street 2:
Practice Address - City:MARINETTE
Practice Address - State:WI
Practice Address - Zip Code:54143-4293
Practice Address - Country:US
Practice Address - Phone:715-732-5111
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-11-16
Last Update Date:2024-10-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI3203225200000X
MI5502007910225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI100191537Medicaid
MI843324594Medicaid