Provider Demographics
NPI:1578215224
Name:CLASH, THERESA
Entity Type:Individual
Prefix:
First Name:THERESA
Middle Name:
Last Name:CLASH
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 1:5218 CRAIGMONT DR
Mailing Address - Street 2:
Mailing Address - City:BARTLETT
Mailing Address - State:TN
Mailing Address - Zip Code:38134-2931
Mailing Address - Country:US
Mailing Address - Phone:501-442-1574
Mailing Address - Fax:
Practice Address - Street 1:5218 CRAIGMONT DR
Practice Address - Street 2:
Practice Address - City:BARTLETT
Practice Address - State:TN
Practice Address - Zip Code:38134
Practice Address - Country:US
Practice Address - Phone:501-442-1574
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-01-24
Last Update Date:2022-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN343900000X
TN142401363343900000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes343900000XTransportation ServicesNon-emergency Medical Transport (VAN)