Provider Demographics
NPI:1609186733
Name:IVERSON, THERESA VIRGINIA (MPT)
Entity Type:Individual
Prefix:MRS
First Name:THERESA
Middle Name:VIRGINIA
Last Name:IVERSON
Suffix:
Gender:F
Credentials:MPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3242 SWEET DR
Mailing Address - Street 2:
Mailing Address - City:LAFAYETTE
Mailing Address - State:CA
Mailing Address - Zip Code:94549-5369
Mailing Address - Country:US
Mailing Address - Phone:925-283-4653
Mailing Address - Fax:
Practice Address - Street 1:1874 TICE VALLEY BLVD.
Practice Address - Street 2:
Practice Address - City:WALNUT CREEK
Practice Address - State:CA
Practice Address - Zip Code:94595
Practice Address - Country:US
Practice Address - Phone:925-283-4653
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-10-07
Last Update Date:2010-10-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA21519225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist