Provider Demographics
NPI:1104354158
Name:KERKVLIET, MARY R (DPT)
Entity type:Individual
Prefix:
First Name:MARY
Middle Name:R
Last Name:KERKVLIET
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:MARY
Other - Middle Name:R
Other - Last Name:SCHLEUSNER
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:630-575-6250
Mailing Address - Fax:630-575-7450
Practice Address - Street 1:815 S MINNESOTA AVE
Practice Address - Street 2:
Practice Address - City:SIOUX FALLS
Practice Address - State:SD
Practice Address - Zip Code:57104-4828
Practice Address - Country:US
Practice Address - Phone:605-231-5586
Practice Address - Fax:605-231-5587
Is Sole Proprietor?:No
Enumeration Date:2017-06-02
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI13866-24225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN11395OtherPT LICENSE
WI13866-24OtherPT LICENSE