Healthcare Provider Details

I. General information

NPI: 1164731725
Provider Name (Legal Business Name): MARY E MOSKAL BUCKLEY DPT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: MARY E MOSKAL DPT

II. Dates (important events)

Enumeration Date: 09/30/2010
Last Update Date: 05/26/2022
Certification Date: 05/26/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12360 PRINCETON DR
HUNTLEY IL
60142-7655
US

IV. Provider business mailing address

2122 YORK RD STE 300
OAK BROOK IL
60523-1925
US

V. Phone/Fax

Practice location:
  • Phone: 847-961-5500
  • Fax: 847-961-5588
Mailing address:
  • Phone: 630-575-1980
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2251X0800X
TaxonomyOrthopedic Physical Therapist
License Number070.017866
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: