Provider Demographics
NPI:1821161563
Name:DEFORE, TESSA LYNN (PTA)
Entity Type:Individual
Prefix:MRS
First Name:TESSA
Middle Name:LYNN
Last Name:DEFORE
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
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Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:406 N 1ST ST
Mailing Address - Street 2:SUITE B
Mailing Address - City:VINCENNES
Mailing Address - State:IN
Mailing Address - Zip Code:47591-1340
Mailing Address - Country:US
Mailing Address - Phone:812-885-2770
Mailing Address - Fax:812-886-4958
Practice Address - Street 1:406 N 1ST ST
Practice Address - Street 2:SUITE B
Practice Address - City:VINCENNES
Practice Address - State:IN
Practice Address - Zip Code:47591-1340
Practice Address - Country:US
Practice Address - Phone:812-885-2770
Practice Address - Fax:812-886-4958
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-17
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN06003155A225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant