Provider Demographics
NPI:1679342893
Name:WONG, THERESA ELAINE (PT, DPT, CLWT, ATC)
Entity type:Individual
Prefix:
First Name:THERESA
Middle Name:ELAINE
Last Name:WONG
Suffix:
Gender:F
Credentials:PT, DPT, CLWT, ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:302 OLD LEBANON DIRT RD
Mailing Address - Street 2:
Mailing Address - City:HERMITAGE
Mailing Address - State:TN
Mailing Address - Zip Code:37076-2386
Mailing Address - Country:US
Mailing Address - Phone:615-391-4545
Mailing Address - Fax:615-391-4546
Practice Address - Street 1:302 OLD LEBANON DIRT RD STE 100
Practice Address - Street 2:
Practice Address - City:HERMITAGE
Practice Address - State:TN
Practice Address - Zip Code:37076-2390
Practice Address - Country:US
Practice Address - Phone:615-391-4545
Practice Address - Fax:615-391-4546
Is Sole Proprietor?:Yes
Enumeration Date:2023-12-28
Last Update Date:2024-11-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN15152225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist