Provider Demographics
NPI:1144267550
Name:TENUTA, CARMELO D (PT)
Entity type:Individual
Prefix:
First Name:CARMELO
Middle Name:D
Last Name:TENUTA
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3921 30TH AVE STE C
Mailing Address - Street 2:
Mailing Address - City:KENOSHA
Mailing Address - State:WI
Mailing Address - Zip Code:53144-1957
Mailing Address - Country:US
Mailing Address - Phone:262-925-5004
Mailing Address - Fax:262-925-5001
Practice Address - Street 1:10222 74TH ST
Practice Address - Street 2:SUITE 211
Practice Address - City:KENOSHA
Practice Address - State:WI
Practice Address - Zip Code:53142-6810
Practice Address - Country:US
Practice Address - Phone:262-925-5020
Practice Address - Fax:262-925-5021
Is Sole Proprietor?:No
Enumeration Date:2006-06-02
Last Update Date:2020-06-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI3494024225100000X, 225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI40178100Medicaid
11231652OtherCAQH
11231652OtherCAQH
WI000185940Medicare ID - Type Unspecified