Provider Demographics
NPI:1700450517
Name:MISANTONI, TINA K
Entity type:Individual
Prefix:
First Name:TINA
Middle Name:K
Last Name:MISANTONI
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1617 GROTON CT
Mailing Address - Street 2:
Mailing Address - City:WHEATON
Mailing Address - State:IL
Mailing Address - Zip Code:60189-7746
Mailing Address - Country:US
Mailing Address - Phone:630-835-7565
Mailing Address - Fax:
Practice Address - Street 1:1555 NAPERVILLEWHEATON RD
Practice Address - Street 2:SUITE 109C
Practice Address - City:NAPERVILLE
Practice Address - State:IL
Practice Address - Zip Code:60563
Practice Address - Country:US
Practice Address - Phone:630-835-7565
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-05-17
Last Update Date:2021-05-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL227006420225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist