Provider Demographics
NPI:1770524308
Name:THOMAS, TESSA L (MPT)
Entity type:Individual
Prefix:
First Name:TESSA
Middle Name:L
Last Name:THOMAS
Suffix:
Gender:F
Credentials:MPT
Other - Prefix:
Other - First Name:TESSA
Other - Middle Name:L
Other - Last Name:DISSMORE
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 727
Mailing Address - Street 2:
Mailing Address - City:DETROIT LAKES
Mailing Address - State:MN
Mailing Address - Zip Code:56502-0727
Mailing Address - Country:US
Mailing Address - Phone:218-844-2300
Mailing Address - Fax:218-844-2444
Practice Address - Street 1:125 FRAZEE ST E
Practice Address - Street 2:
Practice Address - City:DETROIT LAKES
Practice Address - State:MN
Practice Address - Zip Code:56501-3501
Practice Address - Country:US
Practice Address - Phone:218-844-2300
Practice Address - Fax:218-844-2444
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-06-08
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN7686225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MNDA9031015523OtherPREFERRED ONE #
MN51040Medicaid
MN389K1THOtherMNBS #
MN6406152OtherMEDICA #
MNHP59946OtherHEALTHPARTNERS #
MN00051041OtherLHS/BANNERHEALTH #
MN26701OtherNDBS #