Provider Demographics
NPI:1245697879
Name:VAN HORNE, THERESE
Entity type:Individual
Prefix:
First Name:THERESE
Middle Name:
Last Name:VAN HORNE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8119 NEW ST
Mailing Address - Street 2:
Mailing Address - City:MOUNT PLEASANT
Mailing Address - State:NC
Mailing Address - Zip Code:28124-8591
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:700 WALKER RD
Practice Address - Street 2:
Practice Address - City:MOUNT PLEASANT
Practice Address - State:NC
Practice Address - Zip Code:28124-9596
Practice Address - Country:US
Practice Address - Phone:704-214-1622
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-01-27
Last Update Date:2016-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC23712255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer