Provider Demographics
NPI:1760679955
Name:DORE, THERESA ANN (MOTR/L)
Entity Type:Individual
Prefix:
First Name:THERESA
Middle Name:ANN
Last Name:DORE
Suffix:
Gender:F
Credentials:MOTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5041 WATERMAN BLVD
Mailing Address - Street 2:APT. 108
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63108-1164
Mailing Address - Country:US
Mailing Address - Phone:630-624-7942
Mailing Address - Fax:
Practice Address - Street 1:5041 WATERMAN BLVD
Practice Address - Street 2:APT. 108
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63108-1164
Practice Address - Country:US
Practice Address - Phone:630-624-7942
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-10-01
Last Update Date:2007-10-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2007020122225XP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225XP0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistPediatrics