Provider Demographics
NPI:1073910436
Name:TISA, STEPHEN (DPT)
Entity Type:Individual
Prefix:
First Name:STEPHEN
Middle Name:
Last Name:TISA
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 1:14 PARKE PLACE BLVD
Mailing Address - Street 2:SUITE D
Mailing Address - City:SEWELL
Mailing Address - State:NJ
Mailing Address - Zip Code:08080-2661
Mailing Address - Country:US
Mailing Address - Phone:856-256-8393
Mailing Address - Fax:
Practice Address - Street 1:14 PARKE PLACE BLVD
Practice Address - Street 2:SUITE D
Practice Address - City:SEWELL
Practice Address - State:NJ
Practice Address - Zip Code:08080-2661
Practice Address - Country:US
Practice Address - Phone:856-256-8393
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-12-01
Last Update Date:2014-12-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ40QA01584500225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist