Provider Demographics
NPI:1407096530
Name:PRUDENCIO, THERESA M (OTR)
Entity Type:Individual
Prefix:MRS
First Name:THERESA
Middle Name:M
Last Name:PRUDENCIO
Suffix:
Gender:F
Credentials:OTR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11529 CLEAR LAKE WAY
Mailing Address - Street 2:
Mailing Address - City:EL PASO
Mailing Address - State:TX
Mailing Address - Zip Code:79936-4336
Mailing Address - Country:US
Mailing Address - Phone:915-857-5921
Mailing Address - Fax:
Practice Address - Street 1:1831 MURCHISON DR STE C
Practice Address - Street 2:
Practice Address - City:EL PASO
Practice Address - State:TX
Practice Address - Zip Code:79902-2917
Practice Address - Country:US
Practice Address - Phone:915-351-4441
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-03-02
Last Update Date:2009-03-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX108582225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist