Provider Demographics
NPI:1093140584
Name:GIBBONS, TIMOTHY ROBERT (PT)
Entity Type:Individual
Prefix:DR
First Name:TIMOTHY
Middle Name:ROBERT
Last Name:GIBBONS
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:933 W VAN BUREN ST APT 316
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60607-3581
Mailing Address - Country:US
Mailing Address - Phone:401-787-7325
Mailing Address - Fax:
Practice Address - Street 1:1841 W ARMY TRAIL RD
Practice Address - Street 2:
Practice Address - City:ADDISON
Practice Address - State:IL
Practice Address - Zip Code:60101-1901
Practice Address - Country:US
Practice Address - Phone:630-238-9235
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-09-04
Last Update Date:2013-09-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL070.020248225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist