Provider Demographics
NPI:1356747166
Name:MCKOON, THERESA
Entity type:Individual
Prefix:
First Name:THERESA
Middle Name:
Last Name:MCKOON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 5387
Mailing Address - Street 2:
Mailing Address - City:BLOOMINGTON
Mailing Address - State:IL
Mailing Address - Zip Code:61702-5387
Mailing Address - Country:US
Mailing Address - Phone:309-661-8823
Mailing Address - Fax:309-661-8801
Practice Address - Street 1:2750 MOUNT PLEASANT ST
Practice Address - Street 2:
Practice Address - City:BURLINGTON
Practice Address - State:IA
Practice Address - Zip Code:52601-2172
Practice Address - Country:US
Practice Address - Phone:319-752-7727
Practice Address - Fax:309-343-3456
Is Sole Proprietor?:No
Enumeration Date:2014-11-06
Last Update Date:2021-10-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL070-021100225100000X
IA105369225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist