Provider Demographics
NPI:1366402745
Name:THOMAS, TERESA LEE (PT)
Entity type:Individual
Prefix:MRS
First Name:TERESA
Middle Name:LEE
Last Name:THOMAS
Suffix:
Gender:F
Credentials:PT
Other - Prefix:MRS
Other - First Name:TERESA
Other - Middle Name:HAYES
Other - Last Name:THOMAS
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:PT
Mailing Address - Street 1:1685 S SPICELAND RD
Mailing Address - Street 2:
Mailing Address - City:NEW CASTLE
Mailing Address - State:IN
Mailing Address - Zip Code:47362
Mailing Address - Country:US
Mailing Address - Phone:765-529-4656
Mailing Address - Fax:765-529-4656
Practice Address - Street 1:1685 S SPICELAND RD
Practice Address - Street 2:
Practice Address - City:NEW CASTLE
Practice Address - State:IN
Practice Address - Zip Code:47362
Practice Address - Country:US
Practice Address - Phone:765-529-4656
Practice Address - Fax:765-529-4656
Is Sole Proprietor?:Yes
Enumeration Date:2006-03-28
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN05001108A225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN20029210AMedicaid
000000092221OtherANTHEM
IN20029210AMedicaid
000000092221OtherANTHEM