Provider Demographics
NPI:1255512778
Name:COLTRIN, TESSA J (PSYD)
Entity type:Individual
Prefix:
First Name:TESSA
Middle Name:J
Last Name:COLTRIN
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 4046
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:MO
Mailing Address - Zip Code:65808-4046
Mailing Address - Country:US
Mailing Address - Phone:417-269-5712
Mailing Address - Fax:417-269-7567
Practice Address - Street 1:3800 S NATIONAL AVE STE 770
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:MO
Practice Address - Zip Code:65807-5283
Practice Address - Country:US
Practice Address - Phone:417-269-6891
Practice Address - Fax:417-269-5595
Is Sole Proprietor?:No
Enumeration Date:2007-11-27
Last Update Date:2019-10-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2009010491101YP2500X, 103T00000X
MO2007035388101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO431560263OtherTRICARE
AR197065719Medicaid
MOP01173068OtherRR MCR
MO1255512778Medicaid
MO1255512778Medicaid