Provider Demographics
NPI:1780758516
Name:BUCKLEY, SUSAN LYNNE (PT)
Entity type:Individual
Prefix:MRS
First Name:SUSAN
Middle Name:LYNNE
Last Name:BUCKLEY
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4414 STANLEY AVE
Mailing Address - Street 2:
Mailing Address - City:DOWNERS GROVE
Mailing Address - State:IL
Mailing Address - Zip Code:60515-2905
Mailing Address - Country:US
Mailing Address - Phone:630-241-3128
Mailing Address - Fax:630-241-4112
Practice Address - Street 1:4414 STANLEY AVE
Practice Address - Street 2:
Practice Address - City:DOWNERS GROVE
Practice Address - State:IL
Practice Address - Zip Code:60515-2905
Practice Address - Country:US
Practice Address - Phone:630-241-3128
Practice Address - Fax:630-241-4112
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL2232593OtherBLUECROSS BLUE SHIELD
IL325145OtherPHCS
IL7082584OtherAETNA