Provider Demographics
NPI:1124264478
Name:KNOLL, THERESA ANN (MPT)
Entity type:Individual
Prefix:
First Name:THERESA
Middle Name:ANN
Last Name:KNOLL
Suffix:
Gender:F
Credentials:MPT
Other - Prefix:
Other - First Name:THERESA
Other - Middle Name:ANN
Other - Last Name:YANIK
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MPT
Mailing Address - Street 1:210 SE PIONEER WAY
Mailing Address - Street 2:STE 2
Mailing Address - City:OAK HARBOR
Mailing Address - State:WA
Mailing Address - Zip Code:98277-5705
Mailing Address - Country:US
Mailing Address - Phone:360-679-8600
Mailing Address - Fax:
Practice Address - Street 1:3475 S ALPINE RD
Practice Address - Street 2:PHYSICIANS IMMEDIATE CARE
Practice Address - City:ROCKFORD
Practice Address - State:IL
Practice Address - Zip Code:61109-2604
Practice Address - Country:US
Practice Address - Phone:815-874-8000
Practice Address - Fax:815-874-7525
Is Sole Proprietor?:No
Enumeration Date:2008-12-16
Last Update Date:2017-10-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN8149225100000X
IL070017118225100000X
WAPT60736405225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL769380OtherMEDICARE GROUP PTAN
IL10115176OtherBCBS GRP #