Provider Demographics
NPI:1104360643
Name:CORLESS, TERESA (PTA)
Entity Type:Individual
Prefix:
First Name:TERESA
Middle Name:
Last Name:CORLESS
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1310 S LOS ALTOS DR
Mailing Address - Street 2:
Mailing Address - City:CHANDLER
Mailing Address - State:AZ
Mailing Address - Zip Code:85286-6127
Mailing Address - Country:US
Mailing Address - Phone:602-370-9208
Mailing Address - Fax:
Practice Address - Street 1:1310 S LOS ALTOS DR
Practice Address - Street 2:
Practice Address - City:CHANDLER
Practice Address - State:AZ
Practice Address - Zip Code:85286-6127
Practice Address - Country:US
Practice Address - Phone:602-370-9208
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-12-16
Last Update Date:2016-12-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ0034A172V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker