1790951929 NPI number — MS. TERESA ANN WOLLO CRT, RCP

Table of content: MS. TERESA ANN WOLLO CRT, RCP (NPI 1790951929)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1790951929 NPI number — MS. TERESA ANN WOLLO CRT, RCP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
WOLLO
Provider First Name:
TERESA
Provider Middle Name:
ANN
Provider Name Prefix Text:
MS.
Provider Name Suffix Text:
Provider Credential Text:
CRT, RCP
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
CLARKSON
Provider Other First Name:
TERESA
Provider Other Middle Name:
ANN
Provider Other Name Prefix Text:
MISS
Provider Other Name Suffix Text:
Provider Other Credential Text:
CRT,RCP
Provider Other Last Name Type Code:
5

NPI Number Information

NPI Number:
1790951929
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
05/07/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
5925 MAPLE AVE
Provider Second Line Business Mailing Address:
150
Provider Business Mailing Address City Name:
DALLAS
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
75235-6515
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
214-353-9090
Provider Business Mailing Address Fax Number:
214-353-9594

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
5925 MAPLE AVE
Provider Second Line Business Practice Location Address:
150
Provider Business Practice Location Address City Name:
DALLAS
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
75235-6515
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
214-353-9090
Provider Business Practice Location Address Fax Number:
214-353-9594
Provider Enumeration Date:
05/07/2008

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 2278H0200X , with the licence number:  65179 , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 1754376-01 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".




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