Provider Demographics
NPI:1063963098
Name:TUDOR, THERESE (PT)
Entity type:Individual
Prefix:MRS
First Name:THERESE
Middle Name:
Last Name:TUDOR
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 1:77-682 COUNTRY CLUB DRIVE
Mailing Address - Street 2:SUITE G
Mailing Address - City:PALM DESERT
Mailing Address - State:CA
Mailing Address - Zip Code:92211
Mailing Address - Country:US
Mailing Address - Phone:760-345-2200
Mailing Address - Fax:760-345-2210
Practice Address - Street 1:77-682 COUNTRY CLUB DRIVE
Practice Address - Street 2:SUITE G
Practice Address - City:PALM DESERT
Practice Address - State:CA
Practice Address - Zip Code:92211
Practice Address - Country:US
Practice Address - Phone:760-345-2200
Practice Address - Fax:760-345-2210
Is Sole Proprietor?:Yes
Enumeration Date:2016-10-14
Last Update Date:2016-10-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPT15544225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist