Provider Demographics
NPI:1134563513
Name:QUIGLEY, TERA MARIE (AUD)
Entity type:Individual
Prefix:MS
First Name:TERA
Middle Name:MARIE
Last Name:QUIGLEY
Suffix:
Gender:F
Credentials:AUD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:200 S JORDAN AVE
Mailing Address - Street 2:
Mailing Address - City:BLOOMINGTON
Mailing Address - State:IN
Mailing Address - Zip Code:47405-7002
Mailing Address - Country:US
Mailing Address - Phone:812-856-1186
Mailing Address - Fax:
Practice Address - Street 1:200 S JORDAN AVE
Practice Address - Street 2:
Practice Address - City:BLOOMINGTON
Practice Address - State:IN
Practice Address - Zip Code:47405-7002
Practice Address - Country:US
Practice Address - Phone:812-856-1186
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-04-29
Last Update Date:2013-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN23002523A231H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes231H00000XSpeech, Language and Hearing Service ProvidersAudiologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN100276980AMedicaid
IN1982693743Medicare PIN