Healthcare Provider Details

I. General information

NPI: 1093672347
Provider Name (Legal Business Name): THERESSA DEMOSTENE
Entity Type: Individual
Gender:
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/08/2026
Last Update Date: 01/08/2026
Certification Date: 01/08/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2430 COUNTY ROAD 210 W STE B
SAINT JOHNS FL
32259-2451
US

IV. Provider business mailing address

2430 COUNTY ROAD 210 W STE B
SAINT JOHNS FL
32259-2451
US

V. Phone/Fax

Practice location:
  • Phone: 904-717-7782
  • Fax:
Mailing address:
  • Phone: 904-717-7782
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License NumberPTA26396
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: