Provider Demographics
NPI:1689470395
Name:BURT, TESLA
Entity type:Individual
Prefix:
First Name:TESLA
Middle Name:
Last Name:BURT
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 94
Mailing Address - Street 2:
Mailing Address - City:OLD WASHINGTON
Mailing Address - State:OH
Mailing Address - Zip Code:43768-0094
Mailing Address - Country:US
Mailing Address - Phone:740-489-5571
Mailing Address - Fax:740-489-5004
Practice Address - Street 1:239A OLD NATIONAL RD
Practice Address - Street 2:
Practice Address - City:OLD WASHINGTON
Practice Address - State:OH
Practice Address - Zip Code:43768-5000
Practice Address - Country:US
Practice Address - Phone:740-489-5571
Practice Address - Fax:740-489-5004
Is Sole Proprietor?:Yes
Enumeration Date:2025-02-22
Last Update Date:2025-02-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator