Provider Demographics
NPI:1093963969
Name:GENTER, TEDDIE BELLE
Entity Type:Individual
Prefix:
First Name:TEDDIE
Middle Name:BELLE
Last Name:GENTER
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:PO BOX 890
Mailing Address - Street 2:
Mailing Address - City:WACO
Mailing Address - State:TX
Mailing Address - Zip Code:76703-0890
Mailing Address - Country:US
Mailing Address - Phone:254-752-3451
Mailing Address - Fax:254-756-3133
Practice Address - Street 1:110 S 12TH ST
Practice Address - Street 2:
Practice Address - City:WACO
Practice Address - State:TX
Practice Address - Zip Code:76701-1810
Practice Address - Country:US
Practice Address - Phone:254-752-3451
Practice Address - Fax:254-756-3133
Is Sole Proprietor?:No
Enumeration Date:2008-09-04
Last Update Date:2016-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2009012530225XP0200X
CAD2836598101YM0800X
TX117018225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
No225XP0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistPediatrics
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health