Provider Demographics
NPI:1154656072
Name:COMER, TERESA (MOTR/L)
Entity Type:Individual
Prefix:
First Name:TERESA
Middle Name:
Last Name:COMER
Suffix:
Gender:F
Credentials:MOTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4600 BUSINESS PARK BLVD.
Mailing Address - Street 2:SUITE D-24
Mailing Address - City:EAGLE RIVER
Mailing Address - State:AK
Mailing Address - Zip Code:99577
Mailing Address - Country:US
Mailing Address - Phone:907-561-1478
Mailing Address - Fax:
Practice Address - Street 1:10207 STEWART DRIVE
Practice Address - Street 2:
Practice Address - City:EAGLE RIVER
Practice Address - State:AK
Practice Address - Zip Code:99577
Practice Address - Country:US
Practice Address - Phone:405-420-8372
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-10-09
Last Update Date:2018-05-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT7377850-4201225X00000X
AK2148225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AK1577965Medicaid