Provider Demographics
NPI:1033558986
Name:PETZAR, TERESA ANNE (PTA)
Entity type:Individual
Prefix:MS
First Name:TERESA
Middle Name:ANNE
Last Name:PETZAR
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:111 BAY VIEW DR
Mailing Address - Street 2:
Mailing Address - City:INDIAN HARBOUR BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32937-2707
Mailing Address - Country:US
Mailing Address - Phone:321-634-2790
Mailing Address - Fax:
Practice Address - Street 1:111 BAY VIEW DR
Practice Address - Street 2:
Practice Address - City:INDIAN HARBOUR BEACH
Practice Address - State:FL
Practice Address - Zip Code:32937-2707
Practice Address - Country:US
Practice Address - Phone:321-634-2790
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-06-24
Last Update Date:2013-06-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL21889174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist