Provider Demographics
NPI:1720857253
Name:DIAZ, TESSA (DPT)
Entity Type:Individual
Prefix:
First Name:TESSA
Middle Name:
Last Name:DIAZ
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:24454 BOSTON ST
Mailing Address - Street 2:
Mailing Address - City:DEARBORN
Mailing Address - State:MI
Mailing Address - Zip Code:48124-4408
Mailing Address - Country:US
Mailing Address - Phone:734-329-4502
Mailing Address - Fax:
Practice Address - Street 1:15400 NORTHLINE RD
Practice Address - Street 2:
Practice Address - City:SOUTHGATE
Practice Address - State:MI
Practice Address - Zip Code:48195-2689
Practice Address - Country:US
Practice Address - Phone:734-285-0100
Practice Address - Fax:734-285-0101
Is Sole Proprietor?:No
Enumeration Date:2023-12-26
Last Update Date:2024-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5501303164225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist