Provider Demographics
NPI:1851805220
Name:BAUSTIAN, THERESA LYNN (PT)
Entity Type:Individual
Prefix:
First Name:THERESA
Middle Name:LYNN
Last Name:BAUSTIAN
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 1:750 141ST ST
Mailing Address - Street 2:
Mailing Address - City:LUVERNE
Mailing Address - State:MN
Mailing Address - Zip Code:56156-4043
Mailing Address - Country:US
Mailing Address - Phone:507-673-0005
Mailing Address - Fax:
Practice Address - Street 1:1325 S CLIFF AVE
Practice Address - Street 2:PO BOX 5045
Practice Address - City:SIOUX FALLS
Practice Address - State:SD
Practice Address - Zip Code:57117-5045
Practice Address - Country:US
Practice Address - Phone:605-322-5017
Practice Address - Fax:605-322-5040
Is Sole Proprietor?:No
Enumeration Date:2017-11-21
Last Update Date:2017-11-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SD0421225100000X
MN5883225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist