Provider Demographics
NPI:1912080987
Name:THEODORE, CHERUBA (RPT)
Entity Type:Individual
Prefix:MS
First Name:CHERUBA
Middle Name:
Last Name:THEODORE
Suffix:
Gender:F
Credentials:RPT
Other - Prefix:MS
Other - First Name:CHERUBA
Other - Middle Name:
Other - Last Name:JUSTIN
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:RPT
Mailing Address - Street 1:6612 PALISADES
Mailing Address - Street 2:
Mailing Address - City:TEXARKANA
Mailing Address - State:TX
Mailing Address - Zip Code:75503-4972
Mailing Address - Country:US
Mailing Address - Phone:903-781-2437
Mailing Address - Fax:
Practice Address - Street 1:6101 N STATE LINE AVE
Practice Address - Street 2:
Practice Address - City:TEXARKANA
Practice Address - State:TX
Practice Address - Zip Code:75503-5309
Practice Address - Country:US
Practice Address - Phone:903-791-2288
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-23
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1158790225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX1760274Medicaid