Provider Demographics
NPI:1154674323
Name:PERESS-TEETER, SETH JEROME
Entity Type:Individual
Prefix:
First Name:SETH
Middle Name:JEROME
Last Name:PERESS-TEETER
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:310 N WILMOT RD STE 103
Mailing Address - Street 2:
Mailing Address - City:TUCSON
Mailing Address - State:AZ
Mailing Address - Zip Code:85711-2626
Mailing Address - Country:US
Mailing Address - Phone:520-551-3497
Mailing Address - Fax:520-208-9009
Practice Address - Street 1:310 N WILMOT RD STE 103
Practice Address - Street 2:
Practice Address - City:TUCSON
Practice Address - State:AZ
Practice Address - Zip Code:85711-2626
Practice Address - Country:US
Practice Address - Phone:520-551-3497
Practice Address - Fax:520-208-9009
Is Sole Proprietor?:No
Enumeration Date:2012-10-24
Last Update Date:2012-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZMT-11335225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist