Provider Demographics
NPI:1326267477
Name:VASCONCELLOS, TINA
Entity Type:Individual
Prefix:MRS
First Name:TINA
Middle Name:
Last Name:VASCONCELLOS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:417 SCOTCHWOOD RD
Mailing Address - Street 2:
Mailing Address - City:DE PERE
Mailing Address - State:WI
Mailing Address - Zip Code:54115-2457
Mailing Address - Country:US
Mailing Address - Phone:920-883-0661
Mailing Address - Fax:
Practice Address - Street 1:417 SCOTCHWOOD RD
Practice Address - Street 2:
Practice Address - City:DE PERE
Practice Address - State:WI
Practice Address - Zip Code:54115-2457
Practice Address - Country:US
Practice Address - Phone:920-883-0661
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-04-25
Last Update Date:2009-02-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA02088225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist