Provider Demographics
NPI:1376631721
Name:DIAS, THERESA LYNN (COTAL)
Entity Type:Individual
Prefix:MRS
First Name:THERESA
Middle Name:LYNN
Last Name:DIAS
Suffix:
Gender:F
Credentials:COTAL
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:1100 S CLINTON AVENUE
Mailing Address - Street 2:SUITE C
Mailing Address - City:DUNN
Mailing Address - State:NC
Mailing Address - Zip Code:28334
Mailing Address - Country:US
Mailing Address - Phone:910-892-0027
Mailing Address - Fax:910-892-0029
Practice Address - Street 1:1100 S CLINTON AVENUE
Practice Address - Street 2:SUITE C
Practice Address - City:DUNN
Practice Address - State:NC
Practice Address - Zip Code:28334
Practice Address - Country:US
Practice Address - Phone:910-892-0027
Practice Address - Fax:910-892-0029
Is Sole Proprietor?:No
Enumeration Date:2006-10-11
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC5004225100000X, 225X00000X, 235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Not Answered225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Not Answered235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC7211634Medicaid
NC7211634Medicaid