Healthcare Provider Details

I. General information

NPI: 1689650004
Provider Name (Legal Business Name): TIMOTHY DALE KISNER M.P.T.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/16/2005
Last Update Date: 08/13/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4700 GILBERT AVE SUITE 43A
WESTERN SPRINGS IL
60558-1753
US

IV. Provider business mailing address

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

V. Phone/Fax

Practice location:
  • Phone: 708-783-1044
  • Fax: 708-783-1048
Mailing address:
  • Phone: 312-640-0329
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number070-011706
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: