Provider Demographics
NPI:1356648299
Name:ALTIC, TERRI LEE (PTA)
Entity Type:Individual
Prefix:
First Name:TERRI
Middle Name:LEE
Last Name:ALTIC
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 1:1931 E 540TH RD
Mailing Address - Street 2:
Mailing Address - City:PLEASANT HOPE
Mailing Address - State:MO
Mailing Address - Zip Code:65725-9184
Mailing Address - Country:US
Mailing Address - Phone:417-267-2307
Mailing Address - Fax:417-267-6712
Practice Address - Street 1:1931 E 540TH RD
Practice Address - Street 2:
Practice Address - City:PLEASANT HOPE
Practice Address - State:MO
Practice Address - Zip Code:65725-9184
Practice Address - Country:US
Practice Address - Phone:417-267-2307
Practice Address - Fax:417-267-6712
Is Sole Proprietor?:Yes
Enumeration Date:2011-02-11
Last Update Date:2011-02-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO115884225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO115884OtherMISSOURI PTA LICENSE