Provider Demographics
NPI:1962236448
Name:BULSECO, KYLE JEFFREY (PT, DPT)
Entity type:Individual
Prefix:
First Name:KYLE
Middle Name:JEFFREY
Last Name:BULSECO
Suffix:
Gender:M
Credentials:PT, DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 713260
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60677-1260
Mailing Address - Country:US
Mailing Address - Phone:630-469-9200
Mailing Address - Fax:
Practice Address - Street 1:430 PENNSYLVANIA AVE STE 240
Practice Address - Street 2:
Practice Address - City:GLEN ELLYN
Practice Address - State:IL
Practice Address - Zip Code:60137-4464
Practice Address - Country:US
Practice Address - Phone:630-967-2000
Practice Address - Fax:630-545-7816
Is Sole Proprietor?:No
Enumeration Date:2024-08-28
Last Update Date:2024-09-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL070028463225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist