Provider Demographics
NPI:1689919813
Name:ROSS, TERESA KATHRYN (PTA)
Entity Type:Individual
Prefix:
First Name:TERESA
Middle Name:KATHRYN
Last Name:ROSS
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:642 CHALET DR
Mailing Address - Street 2:
Mailing Address - City:BLACK HAWK
Mailing Address - State:CO
Mailing Address - Zip Code:80422-8720
Mailing Address - Country:US
Mailing Address - Phone:303-582-3721
Mailing Address - Fax:
Practice Address - Street 1:642 CHALET DR
Practice Address - Street 2:
Practice Address - City:BLACK HAWK
Practice Address - State:CO
Practice Address - Zip Code:80422-8720
Practice Address - Country:US
Practice Address - Phone:303-582-3721
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-11-28
Last Update Date:2012-11-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COPTA0012445225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant