Healthcare Provider Details

I. General information

NPI: 1629617618
Provider Name (Legal Business Name): ASHLEY TERESIAK
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/23/2019
Last Update Date: 12/23/2019
Certification Date: 12/23/2019
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1251 E RICHTON RD
CRETE IL
60417-1623
US

IV. Provider business mailing address

11721 HARVEST HILL CT
ORLAND PARK IL
60467-7564
US

V. Phone/Fax

Practice location:
  • Phone: 708-567-3189
  • Fax:
Mailing address:
  • Phone: 708-479-0795
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License Number160008512
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: