Provider Demographics
NPI:1699260430
Name:COLEMAN, KENDRALYN
Entity type:Individual
Prefix:
First Name:KENDRALYN
Middle Name:
Last Name:COLEMAN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1040 DIXIE HWY
Mailing Address - Street 2:
Mailing Address - City:CHICAGO HEIGHTS
Mailing Address - State:IL
Mailing Address - Zip Code:60411-2690
Mailing Address - Country:US
Mailing Address - Phone:708-300-6961
Mailing Address - Fax:708-515-9723
Practice Address - Street 1:1040 DIXIE HWY
Practice Address - Street 2:
Practice Address - City:CHICAGO HEIGHTS
Practice Address - State:IL
Practice Address - Zip Code:60411-2690
Practice Address - Country:US
Practice Address - Phone:708-300-6961
Practice Address - Fax:708-515-9723
Is Sole Proprietor?:Yes
Enumeration Date:2018-06-25
Last Update Date:2018-06-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL160007461225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy AssistantGroup - Single Specialty