Provider Demographics
NPI:1114333416
Name:TIEMAN, ELYSIA (PT, DPT)
Entity type:Individual
Prefix:
First Name:ELYSIA
Middle Name:
Last Name:TIEMAN
Suffix:
Gender:
Credentials:PT, DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2122 YORK RD STE 300
Mailing Address - Street 2:
Mailing Address - City:OAK BROOK
Mailing Address - State:IL
Mailing Address - Zip Code:60523-1925
Mailing Address - Country:US
Mailing Address - Phone:630-575-1980
Mailing Address - Fax:
Practice Address - Street 1:4264 N CYPRESS LN STE 103
Practice Address - Street 2:
Practice Address - City:BLOOMINGTON
Practice Address - State:IN
Practice Address - Zip Code:47404-8520
Practice Address - Country:US
Practice Address - Phone:812-727-7720
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-07-08
Last Update Date:2025-04-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
225100000X
IN05011545A225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
INM55585016Medicare PIN