Healthcare Provider Details

I. General information

NPI: 1790695435
Provider Name (Legal Business Name): RENEE PRINCER
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/08/2026
Last Update Date: 09/08/2026
Certification Date: 09/08/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1703 E TAYLOR ST
BLOOMINGTON IL
61701-5665
US

IV. Provider business mailing address

1703 E TAYLOR ST
BLOOMINGTON IL
61701-5665
US

V. Phone/Fax

Practice location:
  • Phone: 309-824-2374
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number070.040882
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: