Healthcare Provider Details

I. General information

NPI: 1134484520
Provider Name (Legal Business Name): DUSTIN STEPHENS PT,DPT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/11/2012
Last Update Date: 07/11/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5230 S BLACKSTONE AVE
CHICAGO IL
60615-4106
US

IV. Provider business mailing address

205 W WACKER DR SUITE 1020
CHICAGO IL
60606-1216
US

V. Phone/Fax

Practice location:
  • Phone: 773-256-1475
  • Fax:
Mailing address:
  • Phone: 312-640-0329
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: