Provider Demographics
NPI:1386989002
Name:PALKOVIC, THERESA LANG (PT)
Entity type:Individual
Prefix:MRS
First Name:THERESA
Middle Name:LANG
Last Name:PALKOVIC
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 1:3050 GUERNSEY ST STE B
Mailing Address - Street 2:
Mailing Address - City:BELLAIRE
Mailing Address - State:OH
Mailing Address - Zip Code:43906-1540
Mailing Address - Country:US
Mailing Address - Phone:740-325-1120
Mailing Address - Fax:740-325-1743
Practice Address - Street 1:7 JUNIOR AVE
Practice Address - Street 2:
Practice Address - City:WHEELING
Practice Address - State:WV
Practice Address - Zip Code:26003-5234
Practice Address - Country:US
Practice Address - Phone:304-780-4401
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-12-06
Last Update Date:2021-05-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHPT008131225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist