Provider Demographics
NPI:1447360938
Name:TEESDALE, AUTUMN
Entity type:Individual
Prefix:
First Name:AUTUMN
Middle Name:
Last Name:TEESDALE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2111 TRAILING VINE RD
Mailing Address - Street 2:
Mailing Address - City:SPRING
Mailing Address - State:TX
Mailing Address - Zip Code:77373-6475
Mailing Address - Country:US
Mailing Address - Phone:713-398-4553
Mailing Address - Fax:
Practice Address - Street 1:15311 VANTAGE PKWY W
Practice Address - Street 2:STE 130
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77032-1954
Practice Address - Country:US
Practice Address - Phone:281-442-6861
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-30
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX2051797OtherLICENSE#