Basic Information
| Provider Information | |||||||||
| NPI: | 1063744480 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | HILL | ||||||||
| FirstName: | THERESA | ||||||||
| MiddleName: | ANN | ||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | YATES | ||||||||
| OtherFirstName: | THERESA | ||||||||
| OtherMiddleName: | ANN | ||||||||
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| OtherCredential: | |||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 7200 SKYWAY | ||||||||
| Address2: | |||||||||
| City: | PARADISE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 959693280 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5308771965 | ||||||||
| FaxNumber: | 5308727784 | ||||||||
| Practice Location | |||||||||
| Address1: | 283 SE FOWLER ST STE 2 | ||||||||
| Address2: | |||||||||
| City: | ROSEBURG | ||||||||
| State: | OR | ||||||||
| PostalCode: | 974703309 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5414646455 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/10/2010 | ||||||||
| LastUpdateDate: | 10/29/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 10/29/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 171M00000X | Y | Other Service Providers | Case Manager/Care Coordinator | 225C00000X | N | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Rehabilitation Counselor |
No ID Information.