Provider Demographics
NPI:1851091235
Name:TELLEZ, ADRIAN
Entity Type:Individual
Prefix:
First Name:ADRIAN
Middle Name:
Last Name:TELLEZ
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:33900 HARPER AVE STE 104
Mailing Address - Street 2:
Mailing Address - City:CLINTON TWP
Mailing Address - State:MI
Mailing Address - Zip Code:48035-4258
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:8317 OGDEN AVE
Practice Address - Street 2:
Practice Address - City:LYONS
Practice Address - State:IL
Practice Address - Zip Code:60534-1122
Practice Address - Country:US
Practice Address - Phone:847-818-0461
Practice Address - Fax:847-305-2917
Is Sole Proprietor?:No
Enumeration Date:2023-03-06
Last Update Date:2023-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL160.009853225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant