Provider Demographics
NPI:1316949217
Name:KONJURA, KATHLEEN (PT)
Entity type:Individual
Prefix:
First Name:KATHLEEN
Middle Name:
Last Name:KONJURA
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1200 N GREEN BAY RD
Mailing Address - Street 2:
Mailing Address - City:WAUKEGAN
Mailing Address - State:IL
Mailing Address - Zip Code:60085-2246
Mailing Address - Country:US
Mailing Address - Phone:847-662-1968
Mailing Address - Fax:847-249-8218
Practice Address - Street 1:1200 N GREEN BAY RD
Practice Address - Street 2:
Practice Address - City:WAUKEGAN
Practice Address - State:IL
Practice Address - Zip Code:60085-2246
Practice Address - Country:US
Practice Address - Phone:847-662-1968
Practice Address - Fax:847-249-8218
Is Sole Proprietor?:No
Enumeration Date:2005-08-11
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL07012489225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL207452Medicare ID - Type UnspecifiedMEDICARE PROVIDER NUMBER