Healthcare Provider Details

I. General information

NPI: 1083695530
Provider Name (Legal Business Name): JILL M BULANOWSKI MPT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/10/2005
Last Update Date: 07/16/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

675 JERICHO TPKE
HUNTINGTON STATION NY
11746-7501
US

IV. Provider business mailing address

675 JERICHO TPKE
HUNTINGTON STATION NY
11746-7501
US

V. Phone/Fax

Practice location:
  • Phone: 631-424-2070
  • Fax: 631-935-1376
Mailing address:
  • Phone: 631-424-2070
  • Fax: 631-935-1376

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number022744
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: