Provider Demographics
NPI:1104186154
Name:REISI, AYDDIN (DPT)
Entity Type:Individual
Prefix:
First Name:AYDDIN
Middle Name:
Last Name:REISI
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7500 N PICCADILLY PL
Mailing Address - Street 2:
Mailing Address - City:PEORIA
Mailing Address - State:IL
Mailing Address - Zip Code:61614-1640
Mailing Address - Country:US
Mailing Address - Phone:309-683-0544
Mailing Address - Fax:
Practice Address - Street 1:7500 N PICCADILLY PL
Practice Address - Street 2:
Practice Address - City:PEORIA
Practice Address - State:IL
Practice Address - Zip Code:61614-1640
Practice Address - Country:US
Practice Address - Phone:309-683-0544
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-05-24
Last Update Date:2012-05-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL070015288225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist