MEDICARE: MS. TASSHENIA BERNICE BALLOW M.P.T.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	225100000X	Physical Therapist	PT015919	PA

General Provider Information

NPI Number	:	1336311372
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. TASSHENIA BERNICE BALLOW M.P.T.

Provider Business Mailing Address
First Line	:	2718 N 8TH ST
Second Line	:
City	:	PHILADELPHIA
State	:	PA
Zip	:	19133-2005
Country	:	US
Telephone Number	:	215-492-1079
Fax Number	:	215-492-1083

Provider Business Practice Location Address
First Line	:	2718 N 8TH ST
Second Line	:
City	:	PHILADELPHIA
State	:	PA
Zip	:	19133-2005
Country	:	US
Telephone Number	:	215-492-1079
Fax Number	:	215-492-1083

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	03/31/2008
Last Update Date	:	03/31/2008

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