Provider Demographics
NPI:1992733133
Name:MALONE, TERESA PHILENE (PHYSICAL THERAPIST)
Entity type:Individual
Prefix:
First Name:TERESA
Middle Name:PHILENE
Last Name:MALONE
Suffix:
Gender:F
Credentials:PHYSICAL THERAPIST
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4801 10TH ST
Mailing Address - Street 2:
Mailing Address - City:GREAT BEND
Mailing Address - State:KS
Mailing Address - Zip Code:67530-3252
Mailing Address - Country:US
Mailing Address - Phone:620-792-7868
Mailing Address - Fax:620-792-7867
Practice Address - Street 1:4801 10TH ST
Practice Address - Street 2:
Practice Address - City:GREAT BEND
Practice Address - State:KS
Practice Address - Zip Code:67530-3542
Practice Address - Country:US
Practice Address - Phone:620-792-7868
Practice Address - Fax:620-792-7867
Is Sole Proprietor?:No
Enumeration Date:2006-06-28
Last Update Date:2017-03-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS11-00515225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS100002840CMedicaid
KS176565Medicare Oscar/Certification