Provider Demographics
NPI:1457386450
Name:TESAURO, RAYMOND R (EDD)
Entity type:Individual
Prefix:DR
First Name:RAYMOND
Middle Name:R
Last Name:TESAURO
Suffix:
Gender:M
Credentials:EDD
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 743
Mailing Address - Street 2:
Mailing Address - City:LEBANON
Mailing Address - State:TN
Mailing Address - Zip Code:37088-0743
Mailing Address - Country:US
Mailing Address - Phone:931-680-4370
Mailing Address - Fax:931-680-4370
Practice Address - Street 1:107 HOLLAND ST
Practice Address - Street 2:
Practice Address - City:SHELBYVILLE
Practice Address - State:TN
Practice Address - Zip Code:37160-3927
Practice Address - Country:US
Practice Address - Phone:931-680-4370
Practice Address - Fax:931-680-4370
Is Sole Proprietor?:No
Enumeration Date:2006-07-11
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNP0000001934103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3687153Medicaid
TN3687158Medicaid
TN3687153Medicaid
TN3687153Medicare ID - Type Unspecified