Provider Demographics
NPI:1780771394
Name:MARIE, TENNILLE E (MS, PT)
Entity type:Individual
Prefix:
First Name:TENNILLE
Middle Name:E
Last Name:MARIE
Suffix:
Gender:F
Credentials:MS, PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:520 PHILADELPHIA ST
Mailing Address - Street 2:
Mailing Address - City:INDIANA
Mailing Address - State:PA
Mailing Address - Zip Code:15701-3902
Mailing Address - Country:US
Mailing Address - Phone:724-463-7478
Mailing Address - Fax:724-463-0931
Practice Address - Street 1:1601 UNION AVE
Practice Address - Street 2:SUITE D
Practice Address - City:NATRONA HEIGHTS
Practice Address - State:PA
Practice Address - Zip Code:15065-2133
Practice Address - Country:US
Practice Address - Phone:724-224-5090
Practice Address - Fax:724-224-5093
Is Sole Proprietor?:No
Enumeration Date:2006-10-06
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAPT013492L225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
PASI602780OtherHIGHMARK BLUE SHIELD
PA206036OtherHEALTH AMER/HEALTH ASSUR.
PA7694334OtherAETNA
PA396749Medicare ID - Type UnspecifiedMEDICARE