Provider Demographics
NPI:1801140694
Name:OPHEIM, TERRA N
Entity type:Individual
Prefix:
First Name:TERRA
Middle Name:N
Last Name:OPHEIM
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:PO BOX 152
Mailing Address - Street 2:
Mailing Address - City:FORT SHAW
Mailing Address - State:MT
Mailing Address - Zip Code:59443-0152
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1701 LEGACY DR STE 1475
Practice Address - Street 2:
Practice Address - City:FRISCO
Practice Address - State:TX
Practice Address - Zip Code:75034-2064
Practice Address - Country:US
Practice Address - Phone:866-930-7088
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-11-01
Last Update Date:2012-11-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX2086993225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant