Provider Demographics
NPI:1720971690
Name:SMITH, TERESA JEAN (PT)
Entity type:Individual
Prefix:
First Name:TERESA
Middle Name:JEAN
Last Name:SMITH
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:TERESA
Other - Middle Name:JEAN
Other - Last Name:WARNER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:13805 KIMBLE RD
Mailing Address - Street 2:
Mailing Address - City:LICKING
Mailing Address - State:MO
Mailing Address - Zip Code:65542-9126
Mailing Address - Country:US
Mailing Address - Phone:573-308-2500
Mailing Address - Fax:
Practice Address - Street 1:200 FLEETWOOD DR
Practice Address - Street 2:
Practice Address - City:WAYNESVILLE
Practice Address - State:MO
Practice Address - Zip Code:65583-2266
Practice Address - Country:US
Practice Address - Phone:573-842-2094
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-05-30
Last Update Date:2025-05-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO105629225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist