Provider Demographics
NPI:1518145507
Name:BRUNSTING, MICHAEL (PTA)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:
Last Name:BRUNSTING
Suffix:
Gender:M
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4801 SOUTHWICK DR
Mailing Address - Street 2:5TH FLOOR
Mailing Address - City:MATTESON
Mailing Address - State:IL
Mailing Address - Zip Code:60443-2254
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:4801 SOUTHWICK DR
Practice Address - Street 2:5TH FLOOR
Practice Address - City:MATTESON
Practice Address - State:IL
Practice Address - Zip Code:60443-2254
Practice Address - Country:US
Practice Address - Phone:708-283-9765
Practice Address - Fax:708-283-9971
Is Sole Proprietor?:No
Enumeration Date:2008-02-01
Last Update Date:2008-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant