Provider Demographics
NPI:1881900991
Name:MANRIQUE, TIANA MARIE (DPT)
Entity type:Individual
Prefix:
First Name:TIANA
Middle Name:MARIE
Last Name:MANRIQUE
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:TIANA
Other - Middle Name:MARIE
Other - Last Name:JUNGELS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PT
Mailing Address - Street 1:600 OAKMONT LN STE 600C
Mailing Address - Street 2:
Mailing Address - City:WESTMONT
Mailing Address - State:IL
Mailing Address - Zip Code:60559-5548
Mailing Address - Country:US
Mailing Address - Phone:630-575-1980
Mailing Address - Fax:
Practice Address - Street 1:67 W JACKSON BLVD # 175
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60604-3507
Practice Address - Country:US
Practice Address - Phone:312-386-1100
Practice Address - Fax:312-386-1200
Is Sole Proprietor?:No
Enumeration Date:2010-08-26
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN05010377A225100000X
IL070018338225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
INP01048545OtherMEDICARE RAILROAD
ILP01023535OtherMEDICARE RAILROAD
INM400063826Medicare PIN
ILP00999818Medicare PIN
ILP01023535OtherMEDICARE RAILROAD
IL216859159Medicare PIN