Provider Demographics
NPI:1932198462
Name:PALLANSCH, THEA L (PT)
Entity Type:Individual
Prefix:
First Name:THEA
Middle Name:L
Last Name:PALLANSCH
Suffix:
Gender:F
Credentials:PT
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 577
Mailing Address - Street 2:1290 N MAIN ST SUITE 3
Mailing Address - City:WEBSTER
Mailing Address - State:SD
Mailing Address - Zip Code:57274
Mailing Address - Country:US
Mailing Address - Phone:605-345-3710
Mailing Address - Fax:605-345-3905
Practice Address - Street 1:1290 NORTH MAIN ST STE 2
Practice Address - Street 2:
Practice Address - City:WEBSTER
Practice Address - State:SD
Practice Address - Zip Code:57274-1114
Practice Address - Country:US
Practice Address - Phone:605-345-3710
Practice Address - Fax:605-345-3905
Is Sole Proprietor?:No
Enumeration Date:2005-10-18
Last Update Date:2017-01-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SD0150225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
SD5831750Medicaid
SD5831750Medicaid