Provider Demographics
NPI:1356674089
Name:TISSENBAUM, CHARLENE (PT)
Entity Type:Individual
Prefix:
First Name:CHARLENE
Middle Name:
Last Name:TISSENBAUM
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:625 LINCOLN AVE STE 107
Mailing Address - Street 2:
Mailing Address - City:CHARLEROI
Mailing Address - State:PA
Mailing Address - Zip Code:15022-2451
Mailing Address - Country:US
Mailing Address - Phone:724-483-1673
Mailing Address - Fax:724-483-0290
Practice Address - Street 1:1146 W CHESTNUT ST
Practice Address - Street 2:
Practice Address - City:WASHINGTON
Practice Address - State:PA
Practice Address - Zip Code:15301-4631
Practice Address - Country:US
Practice Address - Phone:724-223-1207
Practice Address - Fax:724-223-1209
Is Sole Proprietor?:No
Enumeration Date:2009-09-14
Last Update Date:2009-09-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAPT008338L225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist