Provider Demographics
NPI:1881754240
Name:VARNELL, TERESA JO (PT)
Entity type:Individual
Prefix:MS
First Name:TERESA
Middle Name:JO
Last Name:VARNELL
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:TERESA
Other - Middle Name:JO
Other - Last Name:HOUSTON VARNELL
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:501 S ABILENE
Mailing Address - Street 2:
Mailing Address - City:PORTALES
Mailing Address - State:NM
Mailing Address - Zip Code:88130
Mailing Address - Country:US
Mailing Address - Phone:505-359-3707
Mailing Address - Fax:505-356-6682
Practice Address - Street 1:501 S ABILENE
Practice Address - Street 2:
Practice Address - City:PORTALES
Practice Address - State:NM
Practice Address - Zip Code:88130
Practice Address - Country:US
Practice Address - Phone:505-359-3707
Practice Address - Fax:505-356-6682
Is Sole Proprietor?:No
Enumeration Date:2006-12-08
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM897225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NMK0317Medicaid