Provider Demographics
NPI:1689650004
Name:KISNER, TIMOTHY DALE (MPT)
Entity Type:Individual
Prefix:MR
First Name:TIMOTHY
Middle Name:DALE
Last Name:KISNER
Suffix:
Gender:M
Credentials:MPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:205 W WACKER DR
Mailing Address - Street 2:SUITE 1020
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60606-1216
Mailing Address - Country:US
Mailing Address - Phone:312-640-0329
Mailing Address - Fax:
Practice Address - Street 1:4700 GILBERT AVE
Practice Address - Street 2:SUITE 43A
Practice Address - City:WESTERN SPRINGS
Practice Address - State:IL
Practice Address - Zip Code:60558-1753
Practice Address - Country:US
Practice Address - Phone:708-783-1044
Practice Address - Fax:708-783-1048
Is Sole Proprietor?:No
Enumeration Date:2005-12-16
Last Update Date:2014-08-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL070-011706225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist