Provider Demographics
NPI:1356858575
Name:STINE, TERESA (PTA)
Entity Type:Individual
Prefix:
First Name:TERESA
Middle Name:
Last Name:STINE
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 1:542 LINCOLN DR
Mailing Address - Street 2:
Mailing Address - City:ELLSWORTH AFB
Mailing Address - State:SD
Mailing Address - Zip Code:57706-6100
Mailing Address - Country:US
Mailing Address - Phone:217-556-6545
Mailing Address - Fax:
Practice Address - Street 1:224 ELK ST
Practice Address - Street 2:
Practice Address - City:RAPID CITY
Practice Address - State:SD
Practice Address - Zip Code:57701-7359
Practice Address - Country:US
Practice Address - Phone:605-755-7710
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-01-09
Last Update Date:2018-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SD0513225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
SD0516OtherSDBMOE PTA LICENSE