Provider Demographics
NPI:1023311412
Name:WHITE, TERA
Entity type:Individual
Prefix:
First Name:TERA
Middle Name:
Last Name:WHITE
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 1:1400 73RD AVE NE
Mailing Address - Street 2:
Mailing Address - City:FRIDLEY
Mailing Address - State:MN
Mailing Address - Zip Code:55432-3702
Mailing Address - Country:US
Mailing Address - Phone:763-574-5000
Mailing Address - Fax:763-528-7234
Practice Address - Street 1:1400 73RD AVE NE
Practice Address - Street 2:HEALTH CENTER
Practice Address - City:FRIDLEY
Practice Address - State:MN
Practice Address - Zip Code:55432-3702
Practice Address - Country:US
Practice Address - Phone:763-574-5000
Practice Address - Fax:763-528-7234
Is Sole Proprietor?:Yes
Enumeration Date:2010-12-07
Last Update Date:2010-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN103690225X00000X, 225XP0019X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
No225XP0019XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistPhysical Rehabilitation