Provider Demographics
NPI:1215140348
Name:CHENOWETH, AUDREY KIM (MSPT)
Entity type:Individual
Prefix:
First Name:AUDREY
Middle Name:KIM
Last Name:CHENOWETH
Suffix:
Gender:F
Credentials:MSPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:211 E ONTARIO ST
Mailing Address - Street 2:SUITE 1450
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60611-3468
Mailing Address - Country:US
Mailing Address - Phone:312-573-1441
Mailing Address - Fax:312-573-9929
Practice Address - Street 1:211 E ONTARIO ST
Practice Address - Street 2:SUITE 1450
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60611-3468
Practice Address - Country:US
Practice Address - Phone:312-573-1441
Practice Address - Fax:312-573-9929
Is Sole Proprietor?:No
Enumeration Date:2007-05-07
Last Update Date:2007-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL1635145OtherBCBS OF ILLINOIS
IL1635145OtherBCBS OF ILLINOIS