Healthcare Provider Details

I. General information

NPI: 1861052219
Provider Name (Legal Business Name): TESSA DUNIVAN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/18/2019
Last Update Date: 10/08/2026
Certification Date: 10/08/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

205 STATE HIGHWAY P
POTOSI MO
63664-8486
US

IV. Provider business mailing address

3171 HIGHWAY H
FARMINGTON MO
63640-7049
US

V. Phone/Fax

Practice location:
  • Phone: 573-438-2223
  • Fax:
Mailing address:
  • Phone: 573-915-3185
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number2018034573
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: