Provider Demographics
NPI:1407095920
Name:PEDROSO, THERESA (PTA)
Entity type:Individual
Prefix:
First Name:THERESA
Middle Name:
Last Name:PEDROSO
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:257 POLLARD HILL RD
Mailing Address - Street 2:
Mailing Address - City:JOHNSON CITY
Mailing Address - State:NY
Mailing Address - Zip Code:13790-4206
Mailing Address - Country:US
Mailing Address - Phone:607-862-3379
Mailing Address - Fax:
Practice Address - Street 1:257 POLLARD HILL RD
Practice Address - Street 2:
Practice Address - City:JOHNSON CITY
Practice Address - State:NY
Practice Address - Zip Code:13790-4206
Practice Address - Country:US
Practice Address - Phone:607-862-3379
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-02-05
Last Update Date:2009-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY003621-1225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant