Provider Demographics
NPI:1205237021
Name:NIST, TRESA (PTA)
Entity type:Individual
Prefix:MRS
First Name:TRESA
Middle Name:
Last Name:NIST
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:MISS
Other - First Name:TRESA
Other - Middle Name:
Other - Last Name:GALLOWAY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:6125 SPANGLER DR
Mailing Address - Street 2:
Mailing Address - City:NEW FRANKLIN
Mailing Address - State:OH
Mailing Address - Zip Code:44216-8949
Mailing Address - Country:US
Mailing Address - Phone:330-882-3052
Mailing Address - Fax:
Practice Address - Street 1:6125 SPANGLER DR
Practice Address - Street 2:
Practice Address - City:NEW FRANKLIN
Practice Address - State:OH
Practice Address - Zip Code:44216-8949
Practice Address - Country:US
Practice Address - Phone:330-882-3052
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-09-11
Last Update Date:2014-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH01646225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant