Provider Demographics
NPI:1124355235
Name:KONG, LILLIAN (MPT)
Entity type:Individual
Prefix:
First Name:LILLIAN
Middle Name:
Last Name:KONG
Suffix:
Gender:F
Credentials:MPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7411 LAKE ST
Mailing Address - Street 2:SUITE 2190
Mailing Address - City:RIVER FOREST
Mailing Address - State:IL
Mailing Address - Zip Code:60305-1876
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:7411 LAKE ST
Practice Address - Street 2:SUITE 2190
Practice Address - City:RIVER FOREST
Practice Address - State:IL
Practice Address - Zip Code:60305-1876
Practice Address - Country:US
Practice Address - Phone:708-488-1700
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-11-10
Last Update Date:2009-11-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL070.011753225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist