Healthcare Provider Details

I. General information

NPI: 1518004381
Provider Name (Legal Business Name): TRICIA DAWN DEFFENDOLL PTA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/31/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

150 N ROSENBERGER AVE
EVANSVILLE IN
47712-6503
US

IV. Provider business mailing address

8355 KIFER DR
NEWBURGH IN
47630-8907
US

V. Phone/Fax

Practice location:
  • Phone: 812-476-7000
  • Fax:
Mailing address:
  • Phone: 812-490-1447
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License Number06001714A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: