Healthcare Provider Details

I. General information

NPI: 1740567452
Provider Name (Legal Business Name): PATRICIA A BUCKLEY P.T.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: MISS PATRICIA A HILLIARD

II. Dates (important events)

Enumeration Date: 11/08/2011
Last Update Date: 10/21/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1111 TRINITY LANE SUITE 111
BLOOMINGTON IL
61704-3738
US

IV. Provider business mailing address

1111 TRINITY LANE SUITE 111
BLOOMINGTON IL
61704-3738
US

V. Phone/Fax

Practice location:
  • Phone: 309-663-6461
  • Fax: 309-661-8107
Mailing address:
  • Phone: 309-663-6461
  • Fax: 309-661-8107

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number070.007749
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: