Provider Demographics
NPI:1710462841
Name:DUEBERRY, TIEIFA RAQUEL (PTA)
Entity Type:Individual
Prefix:
First Name:TIEIFA
Middle Name:RAQUEL
Last Name:DUEBERRY
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 1:305 W MILL ST
Mailing Address - Street 2:
Mailing Address - City:LIVINGSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77351-3226
Mailing Address - Country:US
Mailing Address - Phone:936-327-4084
Mailing Address - Fax:936-327-1201
Practice Address - Street 1:305 W MILL ST
Practice Address - Street 2:
Practice Address - City:LIVINGSTON
Practice Address - State:TX
Practice Address - Zip Code:77351-3226
Practice Address - Country:US
Practice Address - Phone:936-327-4084
Practice Address - Fax:936-327-1201
Is Sole Proprietor?:No
Enumeration Date:2018-09-25
Last Update Date:2018-09-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX2139205225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant