Provider Demographics
NPI:1417755802
Name:TOLOSA, TATIANNA ROSE
Entity type:Individual
Prefix:
First Name:TATIANNA
Middle Name:ROSE
Last Name:TOLOSA
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1150 S 12TH ST
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19147-4538
Mailing Address - Country:US
Mailing Address - Phone:917-557-2628
Mailing Address - Fax:
Practice Address - Street 1:1919 CHESTNUT ST STE 104
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19103-3456
Practice Address - Country:US
Practice Address - Phone:215-564-1110
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-03-03
Last Update Date:2025-03-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PA225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist