Provider Demographics
NPI:1073629077
Name:TETRUASHVILY, IRMA (DPT,GCS,SCS)
Entity Type:Individual
Prefix:MRS
First Name:IRMA
Middle Name:
Last Name:TETRUASHVILY
Suffix:
Gender:F
Credentials:DPT,GCS,SCS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9 NORMANDY RD
Mailing Address - Street 2:
Mailing Address - City:MARLTON
Mailing Address - State:NJ
Mailing Address - Zip Code:08053-5525
Mailing Address - Country:US
Mailing Address - Phone:856-552-0449
Mailing Address - Fax:856-552-0187
Practice Address - Street 1:9 NORMANDY RD
Practice Address - Street 2:
Practice Address - City:MARLTON
Practice Address - State:NJ
Practice Address - Zip Code:08053-5525
Practice Address - Country:US
Practice Address - Phone:856-552-0449
Practice Address - Fax:856-552-0187
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-22
Last Update Date:2011-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ40QA009886002251G0304X, 2251X0800X, 2251C2600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2251G0304XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGeriatrics
No2251X0800XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistOrthopedic
No2251C2600XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistCardiopulmonary
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ081124Medicare ID - Type UnspecifiedPHYSICAL THERAPY