MEDICARE: TERRI LEE ALTIC P.T.A.

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	225200000X	Physical Therapy Assistant	115884	MO

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	115884	OTHER	MO	MISSOURI PTA LICENSE

General Provider Information

NPI Number	:	1356648299
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	TERRI LEE ALTIC P.T.A.

Provider Business Mailing Address
First Line	:	1931 E 540TH RD
Second Line	:
City	:	PLEASANT HOPE
State	:	MO
Zip	:	65725-9184
Country	:	US
Telephone Number	:	417-267-2307
Fax Number	:	417-267-6712

Provider Business Practice Location Address
First Line	:	1931 E 540TH RD
Second Line	:
City	:	PLEASANT HOPE
State	:	MO
Zip	:	65725-9184
Country	:	US
Telephone Number	:	417-267-2307
Fax Number	:	417-267-6712

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

Provider Enumeration Date	:	02/11/2011
Last Update Date	:	02/11/2011

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