Provider Demographics
NPI:1710226097
Name:POWERS, TERESA LYNN (DT)
Entity Type:Individual
Prefix:MRS
First Name:TERESA
Middle Name:LYNN
Last Name:POWERS
Suffix:
Gender:F
Credentials:DT
Other - Prefix:MISS
Other - First Name:TERESA
Other - Middle Name:LYNN
Other - Last Name:SCOTT
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:210 SHANNON LAKE CIR
Mailing Address - Street 2:
Mailing Address - City:ANNA
Mailing Address - State:IL
Mailing Address - Zip Code:62906-0015
Mailing Address - Country:US
Mailing Address - Phone:618-444-3915
Mailing Address - Fax:
Practice Address - Street 1:210 SHANNON LAKE CIR
Practice Address - Street 2:
Practice Address - City:ANNA
Practice Address - State:IL
Practice Address - Zip Code:62906-0015
Practice Address - Country:US
Practice Address - Phone:618-444-3915
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-02-06
Last Update Date:2013-02-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes252Y00000XAgenciesEarly Intervention Provider Agency