Provider Demographics
NPI:1437284023
Name:DAVIDSON, TERESA ANN (OTR L)
Entity Type:Individual
Prefix:
First Name:TERESA
Middle Name:ANN
Last Name:DAVIDSON
Suffix:
Gender:F
Credentials:OTR L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1983 S FR 69
Mailing Address - Street 2:
Mailing Address - City:REPUBLIC
Mailing Address - State:MO
Mailing Address - Zip Code:65738
Mailing Address - Country:US
Mailing Address - Phone:417-619-1424
Mailing Address - Fax:
Practice Address - Street 1:1983 S FR 69
Practice Address - Street 2:
Practice Address - City:REPUBLIC
Practice Address - State:MO
Practice Address - Zip Code:65738
Practice Address - Country:US
Practice Address - Phone:417-619-1424
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-22
Last Update Date:2008-05-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2003020265225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO478617020Medicaid