Provider Demographics
NPI:1679713234
Name:BULLINER - JOHNSON, TIFFANY R (PT)
Entity Type:Individual
Prefix:
First Name:TIFFANY
Middle Name:R
Last Name:BULLINER - JOHNSON
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:TIFFANY
Other - Middle Name:R
Other - Last Name:BULLINER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PT
Mailing Address - Street 1:625 ENTERPRISE DR.
Mailing Address - Street 2:
Mailing Address - City:OAK BROOK
Mailing Address - State:IL
Mailing Address - Zip Code:60523-8813
Mailing Address - Country:US
Mailing Address - Phone:630-575-6250
Mailing Address - Fax:630-575-7450
Practice Address - Street 1:17751 HALSTED ST
Practice Address - Street 2:
Practice Address - City:HOMEWOOD
Practice Address - State:IL
Practice Address - Zip Code:60430-2009
Practice Address - Country:US
Practice Address - Phone:708-249-8346
Practice Address - Fax:708-957-5465
Is Sole Proprietor?:No
Enumeration Date:2009-02-23
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL070016967225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist