Provider Demographics
NPI:1659002715
Name:BOLLINO, STEPHANIE NICOLE (PTA)
Entity Type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:NICOLE
Last Name:BOLLINO
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:630 W SOUTH ST
Mailing Address - Street 2:
Mailing Address - City:BRADLEY
Mailing Address - State:IL
Mailing Address - Zip Code:60915-2632
Mailing Address - Country:US
Mailing Address - Phone:815-501-0372
Mailing Address - Fax:
Practice Address - Street 1:1390 S CRESCENT ST
Practice Address - Street 2:
Practice Address - City:GILMAN
Practice Address - State:IL
Practice Address - Zip Code:60938-6129
Practice Address - Country:US
Practice Address - Phone:815-265-7208
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-06-20
Last Update Date:2022-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225400000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRehabilitation Practitioner