Basic Information
| Provider Information | |||||||||
| NPI: | 1881021087 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | TISELLANO | ||||||||
| FirstName: | KRISTINA | ||||||||
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| Credential: | DPT | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1243 WOODROW RD STE 321 | ||||||||
| Address2: | |||||||||
| City: | STATEN ISLAND | ||||||||
| State: | NY | ||||||||
| PostalCode: | 103091725 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7188445350 | ||||||||
| FaxNumber: | 7189660005 | ||||||||
| Practice Location | |||||||||
| Address1: | 4010 AVENUE U | ||||||||
| Address2: | |||||||||
| City: | BROOKLYN | ||||||||
| State: | NY | ||||||||
| PostalCode: | 112345118 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7186921155 | ||||||||
| FaxNumber: | 7186921355 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/02/2013 | ||||||||
| LastUpdateDate: | 01/28/2019 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | 40QA01842100 | NJ | N | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist | 225100000X | 022884 | PA | N | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist | 225100000X | 036909 | NY | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
No ID Information.