MEDICARE: TIESHA SHAKEMA' FENWICK

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	2305217040	VA
2	225100000X	Physical Therapist	1406799	TX

General Provider Information

NPI Number	:	1215820188
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	TIESHA SHAKEMA' FENWICK

Provider Business Mailing Address
First Line	:	2001 BUTTERFIELD RD STE 1600
Second Line	:
City	:	DOWNERS GROVE
State	:	IL
Zip	:	60515-1211
Country	:	US
Telephone Number	:	866-370-8206
Fax Number	:

Provider Business Practice Location Address
First Line	:	4617 W BAILEY BOSWELL RD
Second Line	:
City	:	FORT WORTH
State	:	TX
Zip	:	76179-4327
Country	:	US
Telephone Number	:	682-350-4206
Fax Number	:

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

Provider Enumeration Date	:	05/30/2025
Last Update Date	:	06/09/2025

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Directions to “ TIESHA SHAKEMA' FENWICK ” Practice Location

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