Provider Demographics
NPI:1063784643
Name:GENOWAY, TERESA (MPT)
Entity type:Individual
Prefix:
First Name:TERESA
Middle Name:
Last Name:GENOWAY
Suffix:
Gender:F
Credentials:MPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:20732 SHADOW ROCK LN
Mailing Address - Street 2:
Mailing Address - City:TRABUCO CANYON
Mailing Address - State:CA
Mailing Address - Zip Code:92679-3349
Mailing Address - Country:US
Mailing Address - Phone:949-589-6725
Mailing Address - Fax:
Practice Address - Street 1:20732 SHADOW ROCK LN
Practice Address - Street 2:
Practice Address - City:TRABUCO CANYON
Practice Address - State:CA
Practice Address - Zip Code:92679-3349
Practice Address - Country:US
Practice Address - Phone:949-589-6725
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-01-30
Last Update Date:2012-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA17581225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist