Provider Demographics
NPI:1922093418
Name:HORNBUCKLE, MICHAEL GLENN (PTA, ATC)
Entity type:Individual
Prefix:MR
First Name:MICHAEL
Middle Name:GLENN
Last Name:HORNBUCKLE
Suffix:
Gender:M
Credentials:PTA, ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9145 W 103RD ST
Mailing Address - Street 2:
Mailing Address - City:SAINT JOHN
Mailing Address - State:IN
Mailing Address - Zip Code:46373-8794
Mailing Address - Country:US
Mailing Address - Phone:219-319-0110
Mailing Address - Fax:
Practice Address - Street 1:1427 JOLIET ST UNIT C
Practice Address - Street 2:
Practice Address - City:DYER
Practice Address - State:IN
Practice Address - Zip Code:46311-2026
Practice Address - Country:US
Practice Address - Phone:219-319-0110
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-09-12
Last Update Date:2024-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL160.010184225200000X
IN36001065A2255A2300X
IN06006874A225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant
No2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer