Provider Demographics
NPI:1760799464
Name:BUCK, THERESE DAVISSON (PT)
Entity Type:Individual
Prefix:MRS
First Name:THERESE
Middle Name:DAVISSON
Last Name:BUCK
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10300 OLD STATE RD
Mailing Address - Street 2:
Mailing Address - City:MATTOON
Mailing Address - State:IL
Mailing Address - Zip Code:61938-8505
Mailing Address - Country:US
Mailing Address - Phone:217-258-6454
Mailing Address - Fax:
Practice Address - Street 1:101 TROWBRIDGE RD
Practice Address - Street 2:
Practice Address - City:NEOGA
Practice Address - State:IL
Practice Address - Zip Code:62447-1121
Practice Address - Country:US
Practice Address - Phone:217-895-2860
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-09-02
Last Update Date:2010-09-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL070.016713225100000X
MO01908225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist