Provider Demographics
NPI:1043824055
Name:PHAM, THERESA
Entity Type:Individual
Prefix:
First Name:THERESA
Middle Name:
Last Name:PHAM
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2178 FLYNN DR
Mailing Address - Street 2:
Mailing Address - City:GASTONIA
Mailing Address - State:NC
Mailing Address - Zip Code:28054-2935
Mailing Address - Country:US
Mailing Address - Phone:978-548-7837
Mailing Address - Fax:
Practice Address - Street 1:601 MARTIN LUTHER KING JR DR
Practice Address - Street 2:432 FL ATKINS BUILDING
Practice Address - City:WINSTON-SALEM
Practice Address - State:NC
Practice Address - Zip Code:27110-0001
Practice Address - Country:US
Practice Address - Phone:336-750-3174
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-09-07
Last Update Date:2020-09-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program