Provider Demographics
NPI:1316213523
Name:DEVEREAUX, THERESA CAROLINE (PT)
Entity Type:Individual
Prefix:MS
First Name:THERESA
Middle Name:CAROLINE
Last Name:DEVEREAUX
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:22121 CORBETT RD
Mailing Address - Street 2:
Mailing Address - City:BAYSIDE
Mailing Address - State:NY
Mailing Address - Zip Code:11361-2242
Mailing Address - Country:US
Mailing Address - Phone:718-225-8667
Mailing Address - Fax:718-225-9694
Practice Address - Street 1:22121 CORBETT RD
Practice Address - Street 2:
Practice Address - City:BAYSIDE
Practice Address - State:NY
Practice Address - Zip Code:11361-2242
Practice Address - Country:US
Practice Address - Phone:718-225-8667
Practice Address - Fax:718-225-9694
Is Sole Proprietor?:Yes
Enumeration Date:2012-04-02
Last Update Date:2012-04-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY006351-1225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist