Healthcare Provider Details

I. General information

NPI: 1598896979
Provider Name (Legal Business Name): THERASA E QUACKENBUSH MS, ATC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/08/2007
Last Update Date: 07/15/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1678 GLENHAVEN CIR
OCOEE FL
34761-4028
US

IV. Provider business mailing address

1678 GLENHAVEN CIR
OCOEE FL
34761-4028
US

V. Phone/Fax

Practice location:
  • Phone: 317-727-9372
  • Fax:
Mailing address:
  • Phone: 317-727-9372
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: