Provider Demographics
NPI:1255956256
Name:TISERA, GLADYS H
Entity type:Individual
Prefix:
First Name:GLADYS
Middle Name:H
Last Name:TISERA
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 1:1142 CAMELLIA DR
Mailing Address - Street 2:
Mailing Address - City:MUNSTER
Mailing Address - State:IN
Mailing Address - Zip Code:46321-3617
Mailing Address - Country:US
Mailing Address - Phone:312-965-7991
Mailing Address - Fax:
Practice Address - Street 1:1142 CAMELLIA DR
Practice Address - Street 2:
Practice Address - City:MUNSTER
Practice Address - State:IN
Practice Address - Zip Code:46321-3617
Practice Address - Country:US
Practice Address - Phone:312-965-7991
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-06-15
Last Update Date:2020-06-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL227003498225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist