Provider Demographics
NPI:1609829621
Name:PAULSON, TERA DEEANN (PT)
Entity Type:Individual
Prefix:MS
First Name:TERA
Middle Name:DEEANN
Last Name:PAULSON
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:430 5TH ST N
Mailing Address - Street 2:
Mailing Address - City:BRECKENRIDGE
Mailing Address - State:MN
Mailing Address - Zip Code:56520-1426
Mailing Address - Country:US
Mailing Address - Phone:701-242-7323
Mailing Address - Fax:701-242-7797
Practice Address - Street 1:430 5TH ST N
Practice Address - Street 2:
Practice Address - City:BRECKENRIDGE
Practice Address - State:MN
Practice Address - Zip Code:56520-1426
Practice Address - Country:US
Practice Address - Phone:701-242-7323
Practice Address - Fax:701-242-7797
Is Sole Proprietor?:No
Enumeration Date:2006-05-19
Last Update Date:2011-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ6871225100000X
MN7835225100000X
ND1473225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN123437000Medicaid
MN123437000Medicaid