Provider Demographics
NPI:1972980886
Name:BANTASAN, THERESE MAE JOLO (OTR/L)
Entity Type:Individual
Prefix:
First Name:THERESE MAE
Middle Name:JOLO
Last Name:BANTASAN
Suffix:
Gender:F
Credentials:OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6103 BARDU AVE
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:VA
Mailing Address - Zip Code:22152-1802
Mailing Address - Country:US
Mailing Address - Phone:847-271-2017
Mailing Address - Fax:
Practice Address - Street 1:6103 BARDU AVE
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:VA
Practice Address - Zip Code:22152-1802
Practice Address - Country:US
Practice Address - Phone:847-271-2017
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-04-29
Last Update Date:2015-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0119005106225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist