Healthcare Provider Details

I. General information

NPI: 1407466485
Provider Name (Legal Business Name): TERRY LOUISE GEORGE PTA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/05/2020
Last Update Date: 08/05/2020
Certification Date: 08/05/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1303 E HERNDON AVE
FRESNO CA
93720-3309
US

IV. Provider business mailing address

1303 E HERNDON AVE
FRESNO CA
93720-3309
US

V. Phone/Fax

Practice location:
  • Phone: 559-450-3107
  • Fax:
Mailing address:
  • Phone: 559-450-3107
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License Number3479
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: