Provider Demographics
NPI:1093078032
Name:ANTHONY, THERESA ROSEANNE (COTA/L)
Entity Type:Individual
Prefix:MRS
First Name:THERESA
Middle Name:ROSEANNE
Last Name:ANTHONY
Suffix:
Gender:F
Credentials:COTA/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6570 S SPRINGS DR
Mailing Address - Street 2:
Mailing Address - City:CASPER
Mailing Address - State:WY
Mailing Address - Zip Code:82604-5496
Mailing Address - Country:US
Mailing Address - Phone:307-267-8978
Mailing Address - Fax:
Practice Address - Street 1:6570 S SPRINGS DR
Practice Address - Street 2:
Practice Address - City:CASPER
Practice Address - State:WY
Practice Address - Zip Code:82604-5496
Practice Address - Country:US
Practice Address - Phone:307-267-8978
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-06-22
Last Update Date:2012-06-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WY250098174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist