Basic Information
| Provider Information | |||||||||
| NPI: | 1265534705 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | ETTLINGER | ||||||||
| FirstName: | THERESE | ||||||||
| MiddleName: | RENEE | ||||||||
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| Credential: | PT | ||||||||
| OtherOrganizationName: | |||||||||
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| OtherLastName: | ETTLINGER | ||||||||
| OtherFirstName: | TERRI | ||||||||
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| OtherCredential: | PT | ||||||||
| OtherLastNameType: | 5 | ||||||||
| Mailing Information | |||||||||
| Address1: | 1509 RODMAN ST | ||||||||
| Address2: | |||||||||
| City: | HOLLYWOOD | ||||||||
| State: | FL | ||||||||
| PostalCode: | 330206437 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9549220265 | ||||||||
| FaxNumber: | 9549220265 | ||||||||
| Practice Location | |||||||||
| Address1: | 200 SE 19TH AVE | ||||||||
| Address2: | |||||||||
| City: | POMPANO BEACH | ||||||||
| State: | FL | ||||||||
| PostalCode: | 330607543 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9549439589 | ||||||||
| FaxNumber: | 9549434115 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/04/2006 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | PT0004881 | FL | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
No ID Information.