=====================================================
General NPI Number Information
=====================================================
NPI Number | 1538792585
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | CHRISTINE TIELL
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/18/2020
-----------------------------------------------------
Last Update Date | 02/26/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2849 VAN AKEN BLVD APT 2
-----------------------------------------------------
City | CLEVELAND
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 44120-2253
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 567-278-2766
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2849 VAN AKEN BLVD APT 2
-----------------------------------------------------
City | CLEVELAND
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 44120-2253
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 567-278-2766
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 225200000X
-----------------------------------------------------
Taxonomy Name | Physical Therapy Assistant
-----------------------------------------------------
License Number | PTA011092
-----------------------------------------------------
License Number State | OH
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 2255A2300X
-----------------------------------------------------
Taxonomy Name | Athletic Trainer
-----------------------------------------------------
License Number | AT0004234
-----------------------------------------------------
License Number State | OH
-----------------------------------------------------