Provider Demographics
NPI:1740567452
Name:BUCKLEY, PATRICIA A (PT)
Entity Type:Individual
Prefix:MS
First Name:PATRICIA
Middle Name:A
Last Name:BUCKLEY
Suffix:
Gender:F
Credentials:PT
Other - Prefix:MISS
Other - First Name:PATRICIA
Other - Middle Name:A
Other - Last Name:HILLIARD
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1111 TRINITY LANE
Mailing Address - Street 2:SUITE 111
Mailing Address - City:BLOOMINGTON
Mailing Address - State:IL
Mailing Address - Zip Code:61704-3738
Mailing Address - Country:US
Mailing Address - Phone:309-663-6461
Mailing Address - Fax:309-661-8107
Practice Address - Street 1:1111 TRINITY LANE
Practice Address - Street 2:SUITE 111
Practice Address - City:BLOOMINGTON
Practice Address - State:IL
Practice Address - Zip Code:61704-3738
Practice Address - Country:US
Practice Address - Phone:309-663-6461
Practice Address - Fax:309-661-8107
Is Sole Proprietor?:No
Enumeration Date:2011-11-08
Last Update Date:2016-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL070.007749225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL619710007Medicare PIN