Provider Demographics
NPI:1063717577
Name:BRZOSTEK, TERESA
Entity type:Individual
Prefix:
First Name:TERESA
Middle Name:
Last Name:BRZOSTEK
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 1:4232 LIRON AVE APT 201
Mailing Address - Street 2:
Mailing Address - City:FORT MYERS
Mailing Address - State:FL
Mailing Address - Zip Code:33916-7863
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:7460 LAKE BREEZE DR
Practice Address - Street 2:GENESIS REHAB
Practice Address - City:FORT MYERS
Practice Address - State:FL
Practice Address - Zip Code:33907-8090
Practice Address - Country:US
Practice Address - Phone:239-481-6615
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-01-13
Last Update Date:2011-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPTA 18974225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant