Healthcare Provider Details

I. General information

NPI: 1235895079
Provider Name (Legal Business Name): BREANNE BUERSTER PT, DPT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/16/2021
Last Update Date: 07/26/2022
Certification Date: 07/26/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3144 COBALT LN
NOBLE IL
62868-3024
US

IV. Provider business mailing address

3144 COBALT LN
NOBLE IL
62868-3024
US

V. Phone/Fax

Practice location:
  • Phone: 618-843-4521
  • Fax:
Mailing address:
  • Phone: 618-843-4521
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number070.026045
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: