Healthcare Provider Details

I. General information

NPI: 1154065670
Provider Name (Legal Business Name): OLIVIA N TISCKOS
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/21/2022
Last Update Date: 06/18/2025
Certification Date: 06/18/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1122 WEST AVE APT 1
NORMAL IL
61761-3472
US

IV. Provider business mailing address

239 YEOMAN DR
SPRINGFIELD IL
62704-5246
US

V. Phone/Fax

Practice location:
  • Phone: 217-971-0937
  • Fax:
Mailing address:
  • Phone: 217-971-0937
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number096005607
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: