Healthcare Provider Details

I. General information

NPI: 1356858575
Provider Name (Legal Business Name): TERESA STINE PTA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/09/2018
Last Update Date: 01/09/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

224 ELK ST
RAPID CITY SD
57701-7359
US

IV. Provider business mailing address

542 LINCOLN DR
ELLSWORTH AFB SD
57706-6100
US

V. Phone/Fax

Practice location:
  • Phone: 605-755-7710
  • Fax:
Mailing address:
  • Phone: 217-556-6545
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License Number0513
License Number StateSD

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier0516
Identifier TypeOTHER
Identifier StateSD
Identifier IssuerSDBMOE PTA LICENSE

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: