Provider Demographics
NPI:1366183915
Name:HENNESY, THERESA BRIDGES
Entity type:Individual
Prefix:MS
First Name:THERESA
Middle Name:BRIDGES
Last Name:HENNESY
Suffix:
Gender:F
Credentials:
Other - Prefix:MS
Other - First Name:TESSA
Other - Middle Name:BRIDGES
Other - Last Name:HENNESY
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MD
Mailing Address - Street 1:12631 E 17TH AVE
Mailing Address - Street 2:
Mailing Address - City:AURORA
Mailing Address - State:CO
Mailing Address - Zip Code:80045-2527
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:12631 E 17TH AVE
Practice Address - Street 2:
Practice Address - City:AURORA
Practice Address - State:CO
Practice Address - Zip Code:80045-2527
Practice Address - Country:US
Practice Address - Phone:720-848-2820
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-04-06
Last Update Date:2023-03-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
COTL.0009096207Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngology
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program