Provider Demographics
NPI:1851140438
Name:SHENORA, THERESA (MMT, CMLDT)
Entity type:Individual
Prefix:
First Name:THERESA
Middle Name:
Last Name:SHENORA
Suffix:
Gender:F
Credentials:MMT, CMLDT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:925 CROW MOUNTAIN RD
Mailing Address - Street 2:
Mailing Address - City:RUSSELLVILLE
Mailing Address - State:AR
Mailing Address - Zip Code:72802-1945
Mailing Address - Country:US
Mailing Address - Phone:479-970-0644
Mailing Address - Fax:
Practice Address - Street 1:925 CROW MOUNTAIN RD
Practice Address - Street 2:
Practice Address - City:RUSSELLVILLE
Practice Address - State:AR
Practice Address - Zip Code:72802-1945
Practice Address - Country:US
Practice Address - Phone:479-970-0644
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-05-15
Last Update Date:2024-05-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR9085225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist