Provider Demographics
NPI:1548924822
Name:DAVIS, THERESA
Entity type:Individual
Prefix:
First Name:THERESA
Middle Name:
Last Name:DAVIS
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 1:1073 ROTH AVE
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63130-2542
Mailing Address - Country:US
Mailing Address - Phone:314-267-2165
Mailing Address - Fax:
Practice Address - Street 1:2963 DODDRIDGE AVE
Practice Address - Street 2:
Practice Address - City:MARYLAND HEIGHTS
Practice Address - State:MO
Practice Address - Zip Code:63043-1736
Practice Address - Country:US
Practice Address - Phone:314-291-4557
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-10-24
Last Update Date:2021-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2017036512225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant