Provider Demographics
NPI:1407237936
Name:GILLIBRAND, AUTUMN (DPT)
Entity Type:Individual
Prefix:
First Name:AUTUMN
Middle Name:
Last Name:GILLIBRAND
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:790 REMINGTON BLVD
Mailing Address - Street 2:
Mailing Address - City:BOLINGBROOK
Mailing Address - State:IL
Mailing Address - Zip Code:60440-4909
Mailing Address - Country:US
Mailing Address - Phone:630-296-2223
Mailing Address - Fax:630-759-9510
Practice Address - Street 1:200 E CEDAR ST
Practice Address - Street 2:SUITE C
Practice Address - City:LE ROY
Practice Address - State:IL
Practice Address - Zip Code:61752-1902
Practice Address - Country:US
Practice Address - Phone:309-962-3240
Practice Address - Fax:309-962-3243
Is Sole Proprietor?:No
Enumeration Date:2015-06-10
Last Update Date:2016-12-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL070021382225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL1407801012OtherGROUP NPI