Provider Demographics
NPI:1992816516
Name:FELLOWS, KIMBERLY (PT)
Entity type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:
Last Name:FELLOWS
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:900 RAND RD
Mailing Address - Street 2:SUITE 300
Mailing Address - City:DES PLAINES
Mailing Address - State:IL
Mailing Address - Zip Code:60016-2359
Mailing Address - Country:US
Mailing Address - Phone:847-324-3091
Mailing Address - Fax:
Practice Address - Street 1:1025 RED OAK LN
Practice Address - Street 2:SUITE 100
Practice Address - City:LINDENHURST
Practice Address - State:IL
Practice Address - Zip Code:60046-5017
Practice Address - Country:US
Practice Address - Phone:847-245-7175
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-31
Last Update Date:2013-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL070-013231225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILK32100Medicare PIN
ILK32099Medicare PIN