Provider Demographics
NPI:1053734442
Name:DIERCKS, TERESA CANALES (OTR/L)
Entity type:Individual
Prefix:
First Name:TERESA
Middle Name:CANALES
Last Name:DIERCKS
Suffix:
Gender:F
Credentials:OTR/L
Other - Prefix:
Other - First Name:TERESA
Other - Middle Name:CANALES
Other - Last Name:GONZALES
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:501 W BEESON RD
Mailing Address - Street 2:
Mailing Address - City:DODGE CITY
Mailing Address - State:KS
Mailing Address - Zip Code:67801-5915
Mailing Address - Country:US
Mailing Address - Phone:620-227-7512
Mailing Address - Fax:
Practice Address - Street 1:8601 N DAVIS HWY
Practice Address - Street 2:
Practice Address - City:PENSACOLA
Practice Address - State:FL
Practice Address - Zip Code:32514-5932
Practice Address - Country:US
Practice Address - Phone:850-390-4091
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-01-21
Last Update Date:2022-07-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS17-02954225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist