Provider Demographics
NPI:1669636338
Name:SIDEBOTTOM, TERESA ANN
Entity Type:Individual
Prefix:
First Name:TERESA
Middle Name:ANN
Last Name:SIDEBOTTOM
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 1:6139 SCOTTSVILLE RD
Mailing Address - Street 2:
Mailing Address - City:FLOYDS KNOBS
Mailing Address - State:IN
Mailing Address - Zip Code:47119-9229
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:101 POTTERS LN
Practice Address - Street 2:
Practice Address - City:CLARKSVILLE
Practice Address - State:IN
Practice Address - Zip Code:47129-1017
Practice Address - Country:US
Practice Address - Phone:812-948-0808
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-07-11
Last Update Date:2008-07-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN05004518A225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist