Provider Demographics
NPI:1063001048
Name:TESORO-RACELIS, SEAN NIKO (DPT)
Entity Type:Individual
Prefix:
First Name:SEAN
Middle Name:NIKO
Last Name:TESORO-RACELIS
Suffix:
Gender:M
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1104 HECKEL DR
Mailing Address - Street 2:
Mailing Address - City:MOUNTAINSIDE
Mailing Address - State:NJ
Mailing Address - Zip Code:07092-2029
Mailing Address - Country:US
Mailing Address - Phone:908-868-9227
Mailing Address - Fax:
Practice Address - Street 1:355 GRAND ST
Practice Address - Street 2:
Practice Address - City:JERSEY CITY
Practice Address - State:NJ
Practice Address - Zip Code:07302-4321
Practice Address - Country:US
Practice Address - Phone:201-915-2000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-01-13
Last Update Date:2021-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ40QA01924500225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist