Provider Demographics
NPI:1033235858
Name:HAILEY, TISHA LEN (OTRL)
Entity Type:Individual
Prefix:
First Name:TISHA
Middle Name:LEN
Last Name:HAILEY
Suffix:
Gender:F
Credentials:OTRL
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1519 RIDGE BROOK DR
Mailing Address - Street 2:
Mailing Address - City:JOLIET
Mailing Address - State:IL
Mailing Address - Zip Code:60431-5348
Mailing Address - Country:US
Mailing Address - Phone:815-436-7988
Mailing Address - Fax:
Practice Address - Street 1:421 DORIS AVE
Practice Address - Street 2:
Practice Address - City:JOLIET
Practice Address - State:IL
Practice Address - Zip Code:60433-2569
Practice Address - Country:US
Practice Address - Phone:815-727-8776
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-03-22
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist