Healthcare Provider Details

I. General information

NPI: 1326672262
Provider Name (Legal Business Name): RONNAE TESSELY OT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/01/2020
Last Update Date: 03/01/2020
Certification Date: 03/01/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5024 W WESTERN AVE
SOUTH BEND IN
46619-2312
US

IV. Provider business mailing address

5232 N FALLS CHURCH CT
SOUTH BEND IN
46614-5944
US

V. Phone/Fax

Practice location:
  • Phone: 574-318-4600
  • Fax:
Mailing address:
  • Phone: 574-252-9766
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225XP0019X
TaxonomyPhysical Rehabilitation Occupational Therapist
License Number31003236A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: