Provider Demographics
NPI:1235451972
Name:TEJADA, NELISA MARIE (PT)
Entity Type:Individual
Prefix:MS
First Name:NELISA
Middle Name:MARIE
Last Name:TEJADA
Suffix:
Gender:F
Credentials:PT
Other - Prefix:MS
Other - First Name:NELISA
Other - Middle Name:MARIE
Other - Last Name:STO TOMAS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PT
Mailing Address - Street 1:655 W IRVING PARK RD
Mailing Address - Street 2:UNIT 2917
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60613-3123
Mailing Address - Country:US
Mailing Address - Phone:773-388-0661
Mailing Address - Fax:
Practice Address - Street 1:655 W IRVING PARK RD
Practice Address - Street 2:UNIT 2917
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60613-3123
Practice Address - Country:US
Practice Address - Phone:773-388-0661
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-02-22
Last Update Date:2010-02-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL070-008973225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist