Provider Demographics
NPI:1033681713
Name:KESTERSON, TAMMY SUE (BS)
Entity Type:Individual
Prefix:
First Name:TAMMY
Middle Name:SUE
Last Name:KESTERSON
Suffix:
Gender:F
Credentials:BS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:664 W COUNTY ROAD 600 N
Mailing Address - Street 2:
Mailing Address - City:ORLEANS
Mailing Address - State:IN
Mailing Address - Zip Code:47452-9719
Mailing Address - Country:US
Mailing Address - Phone:812-865-4326
Mailing Address - Fax:812-865-4326
Practice Address - Street 1:664 W COUNTY ROAD 600 N
Practice Address - Street 2:
Practice Address - City:ORLEANS
Practice Address - State:IN
Practice Address - Zip Code:47452-9719
Practice Address - Country:US
Practice Address - Phone:812-865-4326
Practice Address - Fax:812-865-4326
Is Sole Proprietor?:Yes
Enumeration Date:2018-12-19
Last Update Date:2018-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
252Y00000X
IN437823222Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes222Q00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersDevelopmental TherapistGroup - Single Specialty
No252Y00000XAgenciesEarly Intervention Provider AgencyGroup - Single Specialty