Provider Demographics
NPI:1942344908
Name:FORTNER, TERESA M (MOT OTR L)
Entity Type:Individual
Prefix:
First Name:TERESA
Middle Name:M
Last Name:FORTNER
Suffix:
Gender:F
Credentials:MOT OTR L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3512 FOY GLEN CT
Mailing Address - Street 2:
Mailing Address - City:APEX
Mailing Address - State:NC
Mailing Address - Zip Code:27539-3682
Mailing Address - Country:US
Mailing Address - Phone:919-815-0638
Mailing Address - Fax:
Practice Address - Street 1:3716 NATIONAL DR
Practice Address - Street 2:SUITE 124
Practice Address - City:RALEIGH
Practice Address - State:NC
Practice Address - Zip Code:27612-4068
Practice Address - Country:US
Practice Address - Phone:919-815-0638
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-02-16
Last Update Date:2015-10-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC4712225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist