Provider Demographics
NPI:1124290887
Name:MONJARDIN, THERESE THEA T (PT)
Entity type:Individual
Prefix:MS
First Name:THERESE THEA
Middle Name:T
Last Name:MONJARDIN
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 1:716 18TH ST
Mailing Address - Street 2:
Mailing Address - City:CHARLESTON
Mailing Address - State:IL
Mailing Address - Zip Code:61920-2382
Mailing Address - Country:US
Mailing Address - Phone:217-345-7054
Mailing Address - Fax:
Practice Address - Street 1:716 18TH ST
Practice Address - Street 2:
Practice Address - City:CHARLESTON
Practice Address - State:IL
Practice Address - Zip Code:61920-2382
Practice Address - Country:US
Practice Address - Phone:417-291-1655
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-04-01
Last Update Date:2013-02-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL070.015578225100000X
MO2006007052225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist