Provider Demographics
NPI:1760633721
Name:FLETCHER, TALA (DPT)
Entity Type:Individual
Prefix:MS
First Name:TALA
Middle Name:
Last Name:FLETCHER
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:TALA
Other - Middle Name:
Other - Last Name:FAKHOURI
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DPT
Mailing Address - Street 1:2122 YORK RD STE 300
Mailing Address - Street 2:
Mailing Address - City:OAK BROOK
Mailing Address - State:IL
Mailing Address - Zip Code:60523-1925
Mailing Address - Country:US
Mailing Address - Phone:630-575-1980
Mailing Address - Fax:
Practice Address - Street 1:8729 RIDGELAND AVE
Practice Address - Street 2:
Practice Address - City:OAK LAWN
Practice Address - State:IL
Practice Address - Zip Code:60453-1001
Practice Address - Country:US
Practice Address - Phone:708-233-6363
Practice Address - Fax:708-233-5580
Is Sole Proprietor?:No
Enumeration Date:2008-10-08
Last Update Date:2021-04-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL0700167352251S0007X, 2251X0800X, 225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
No2251S0007XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistSports
No2251X0800XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistOrthopedic