MEDICARE: THERESA JANE DEBORD PMHNP-BC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363LP0808X	Psychiatric/Mental Health Nurse Practitioner	2025011453	MO

General Provider Information

NPI Number	:	1134772353
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	THERESA JANE DEBORD PMHNP-BC

Provider Business Mailing Address
First Line	:	129 BROOKSHIRE CREEK DR
Second Line	:
City	:	WENTZVILLE
State	:	MO
Zip	:	63385-5593
Country	:	US
Telephone Number	:	636-200-7187
Fax Number	:

Provider Business Practice Location Address
First Line	:	129 BROOKSHIRE CREEK DR
Second Line	:
City	:	WENTZVILLE
State	:	MO
Zip	:	63385-5593
Country	:	US
Telephone Number	:	636-200-7187
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/17/2019
Last Update Date	:	05/20/2026

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