Provider Demographics
NPI:1306124383
Name:LICKTEIG, KASANDRA L (DPT)
Entity type:Individual
Prefix:
First Name:KASANDRA
Middle Name:L
Last Name:LICKTEIG
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:790 REMINGTON BLVD
Mailing Address - Street 2:
Mailing Address - City:BOLINGBROOK
Mailing Address - State:IL
Mailing Address - Zip Code:60440-4909
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:410 E 22ND ST
Practice Address - Street 2:
Practice Address - City:FREMONT
Practice Address - State:NE
Practice Address - Zip Code:68025-2609
Practice Address - Country:US
Practice Address - Phone:402-721-3908
Practice Address - Fax:402-721-4047
Is Sole Proprietor?:No
Enumeration Date:2011-07-25
Last Update Date:2024-06-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE3023225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NE47649OtherBLUE CROSS BLUE SHIELD
NEP01003060OtherRAILROAD MEDICARE
NE47649OtherBLUE CROSS BLUE SHIELD