Provider Demographics
NPI:1033280680
Name:SPONG, THERESA M (PT)
Entity Type:Individual
Prefix:
First Name:THERESA
Middle Name:M
Last Name:SPONG
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:THERESA
Other - Middle Name:M
Other - Last Name:SCHOENER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1611 HEADWAY CIR BLDG 2
Mailing Address - Street 2:
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78754-5165
Mailing Address - Country:US
Mailing Address - Phone:512-478-2581
Mailing Address - Fax:512-476-1638
Practice Address - Street 1:1611 HEADWAY CIR
Practice Address - Street 2:BLDG. 2
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78754-5160
Practice Address - Country:US
Practice Address - Phone:512-478-2581
Practice Address - Fax:512-476-1638
Is Sole Proprietor?:No
Enumeration Date:2006-11-13
Last Update Date:2008-05-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1045953225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX126129901Medicaid
TX021286202Medicaid
TX021286201Medicaid