Provider Demographics
NPI:1912159872
Name:TRUMBULL, PAUL (PT)
Entity Type:Individual
Prefix:MR
First Name:PAUL
Middle Name:
Last Name:TRUMBULL
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:412 LAKE SHORE CIR
Mailing Address - Street 2:
Mailing Address - City:BLOOMINGTON
Mailing Address - State:IL
Mailing Address - Zip Code:61704-1433
Mailing Address - Country:US
Mailing Address - Phone:309-661-2710
Mailing Address - Fax:
Practice Address - Street 1:412 LAKE SHORE CIR
Practice Address - Street 2:
Practice Address - City:BLOOMINGTON
Practice Address - State:IL
Practice Address - Zip Code:61704-1433
Practice Address - Country:US
Practice Address - Phone:309-661-2710
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-10-22
Last Update Date:2008-10-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL070007148225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist