MEDICARE: ADESOLA ABIGAIL TELLA DPT

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	028818	NY

General Provider Information

NPI Number	:	1336355080
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	ADESOLA ABIGAIL TELLA DPT

Provider Business Mailing Address
First Line	:	353A MONROE ST
Second Line	:
City	:	BROOKLYN
State	:	NY
Zip	:	11221-1104
Country	:	US
Telephone Number	:	347-351-5869
Fax Number	:

Provider Business Practice Location Address
First Line	:	4319 CHURCH AVE
Second Line	:
City	:	BROOKLYN
State	:	NY
Zip	:	11203-3101
Country	:	US
Telephone Number	:	347-351-5869
Fax Number	:

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

Provider Enumeration Date	:	05/16/2007
Last Update Date	:	03/21/2017

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