Provider Demographics
NPI:1740652320
Name:BERT, TEODORA
Entity type:Individual
Prefix:
First Name:TEODORA
Middle Name:
Last Name:BERT
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:105 W FRONT ST
Mailing Address - Street 2:
Mailing Address - City:MONROE
Mailing Address - State:MI
Mailing Address - Zip Code:48161-2338
Mailing Address - Country:US
Mailing Address - Phone:734-242-1700
Mailing Address - Fax:
Practice Address - Street 1:105 W FRONT ST
Practice Address - Street 2:
Practice Address - City:MONROE
Practice Address - State:MI
Practice Address - Zip Code:48161-2338
Practice Address - Country:US
Practice Address - Phone:734-242-1700
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-10-22
Last Update Date:2015-10-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MIL875112225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist