Provider Demographics
NPI:1063015683
Name:FERNANDEZ, TESORO MARIE (MASSAGE THERAPIST)
Entity type:Individual
Prefix:
First Name:TESORO
Middle Name:MARIE
Last Name:FERNANDEZ
Suffix:
Gender:F
Credentials:MASSAGE THERAPIST
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1010 AVENUE S
Mailing Address - Street 2:
Mailing Address - City:HONDO
Mailing Address - State:TX
Mailing Address - Zip Code:78861-1135
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1010 AVENUE S
Practice Address - Street 2:
Practice Address - City:HONDO
Practice Address - State:TX
Practice Address - Zip Code:78861-1135
Practice Address - Country:US
Practice Address - Phone:210-296-7690
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-11-17
Last Update Date:2020-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXMT117561225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist