Provider Demographics
NPI:1700071537
Name:GASTON, TERI MARIE (OTR/L)
Entity Type:Individual
Prefix:
First Name:TERI
Middle Name:MARIE
Last Name:GASTON
Suffix:
Gender:F
Credentials:OTR/L
Other - Prefix:
Other - First Name:TERI
Other - Middle Name:MARIE
Other - Last Name:APPLETON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:OTR/L
Mailing Address - Street 1:315 E CLINTON ST
Mailing Address - Street 2:
Mailing Address - City:HOBBS
Mailing Address - State:NM
Mailing Address - Zip Code:88240-8238
Mailing Address - Country:US
Mailing Address - Phone:505-393-0755
Mailing Address - Fax:505-393-0249
Practice Address - Street 1:315 E CLINTON ST
Practice Address - Street 2:
Practice Address - City:HOBBS
Practice Address - State:NM
Practice Address - Zip Code:88240-8238
Practice Address - Country:US
Practice Address - Phone:505-393-0755
Practice Address - Fax:505-393-0249
Is Sole Proprietor?:Yes
Enumeration Date:2007-09-14
Last Update Date:2007-09-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM1609225X00000X
TX111498225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM0000A3144Medicaid