Provider Demographics
NPI:1457356438
Name:MOTT, THERESA (CNM)
Entity Type:Individual
Prefix:MS
First Name:THERESA
Middle Name:
Last Name:MOTT
Suffix:
Gender:F
Credentials:CNM
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 66308
Mailing Address - Street 2:
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77266-6308
Mailing Address - Country:US
Mailing Address - Phone:409-781-3217
Mailing Address - Fax:713-559-3255
Practice Address - Street 1:740 HOSPITAL DR
Practice Address - Street 2:SUITE 250
Practice Address - City:BEAUMONT
Practice Address - State:TX
Practice Address - Zip Code:77701-4664
Practice Address - Country:US
Practice Address - Phone:409-212-1000
Practice Address - Fax:409-813-3302
Is Sole Proprietor?:No
Enumeration Date:2005-06-16
Last Update Date:2015-09-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX11274367A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367A00000XPhysician Assistants & Advanced Practice Nursing ProvidersAdvanced Practice Midwife
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXS86005Medicare UPIN
TX8B3275Medicare PIN