MEDICARE: THERESA GOLDSTROHM PTA

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	TE004082L	PA

General Provider Information

NPI Number	:	1740485788
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	THERESA GOLDSTROHM PTA

Provider Business Mailing Address
First Line	:	PO BOX 174
Second Line	:
City	:	YATESBORO
State	:	PA
Zip	:	16263-0174
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	16405 NORTHCROSS DR
Second Line	:	SUITE G2
City	:	HUNTERSVILLE
State	:	NC
Zip	:	28078-5091
Country	:	US
Telephone Number	:	704-897-2450
Fax Number	:

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

Provider Enumeration Date	:	06/19/2007
Last Update Date	:	07/08/2007

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