Provider Demographics
NPI:1598896979
Name:QUACKENBUSH, THERASA E (MS, ATC)
Entity Type:Individual
Prefix:
First Name:THERASA
Middle Name:E
Last Name:QUACKENBUSH
Suffix:
Gender:F
Credentials:MS, ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1678 GLENHAVEN CIR
Mailing Address - Street 2:
Mailing Address - City:OCOEE
Mailing Address - State:FL
Mailing Address - Zip Code:34761-4028
Mailing Address - Country:US
Mailing Address - Phone:317-727-9372
Mailing Address - Fax:
Practice Address - Street 1:1678 GLENHAVEN CIR
Practice Address - Street 2:
Practice Address - City:OCOEE
Practice Address - State:FL
Practice Address - Zip Code:34761-4028
Practice Address - Country:US
Practice Address - Phone:317-727-9372
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-08
Last Update Date:2014-07-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer