Provider Demographics
NPI:1518415256
Name:TEASLEY, TICESES
Entity Type:Individual
Prefix:
First Name:TICESES
Middle Name:
Last Name:TEASLEY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:500 FAIRWAY DR.
Mailing Address - Street 2:SUIT 102
Mailing Address - City:DEERFIELD BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:33441
Mailing Address - Country:US
Mailing Address - Phone:888-880-9270
Mailing Address - Fax:
Practice Address - Street 1:780 LYNNHAVEN PKWY
Practice Address - Street 2:SUITE 400
Practice Address - City:VIRGINIA BEACH
Practice Address - State:VA
Practice Address - Zip Code:23452-7332
Practice Address - Country:US
Practice Address - Phone:757-452-7579
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-09-12
Last Update Date:2016-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes222Q00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersDevelopmental Therapist