Provider Demographics
NPI:1780468009
Name:PELESCO, BRET TIBAY (PT, DPT)
Entity type:Individual
Prefix:
First Name:BRET
Middle Name:TIBAY
Last Name:PELESCO
Suffix:
Gender:M
Credentials:PT, DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:102 BROSMAN LN APT 2
Mailing Address - Street 2:
Mailing Address - City:MARSHALL
Mailing Address - State:IL
Mailing Address - Zip Code:62441-1096
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:410 N 2ND ST
Practice Address - Street 2:
Practice Address - City:MARSHALL
Practice Address - State:IL
Practice Address - Zip Code:62441-1010
Practice Address - Country:US
Practice Address - Phone:217-826-2358
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-08-21
Last Update Date:2023-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL070027209225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist