Provider Demographics
NPI:1578734711
Name:TYSSELING MATTIACE, VICKI MARIA (PT)
Entity Type:Individual
Prefix:
First Name:VICKI
Middle Name:MARIA
Last Name:TYSSELING MATTIACE
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 1:124 W POLK ST APT 807
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60605-1767
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:124 W POLK ST APT 807
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60605-1767
Practice Address - Country:US
Practice Address - Phone:312-583-9077
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-03-16
Last Update Date:2008-03-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist