Provider Demographics
NPI:1336975655
Name:ILLESCAS, MARITA (DPT)
Entity type:Individual
Prefix:MRS
First Name:MARITA
Middle Name:
Last Name:ILLESCAS
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:MARITA
Other - Middle Name:
Other - Last Name:MILLER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:235 E HIGH ST
Mailing Address - Street 2:
Mailing Address - City:MOORESVILLE
Mailing Address - State:IN
Mailing Address - Zip Code:46158-1639
Mailing Address - Country:US
Mailing Address - Phone:317-371-8180
Mailing Address - Fax:833-925-2447
Practice Address - Street 1:235 E HIGH ST
Practice Address - Street 2:
Practice Address - City:MOORESVILLE
Practice Address - State:IN
Practice Address - Zip Code:46158-1639
Practice Address - Country:US
Practice Address - Phone:317-371-8180
Practice Address - Fax:833-925-2447
Is Sole Proprietor?:No
Enumeration Date:2024-09-12
Last Update Date:2024-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN05013849A225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist