Basic Information
| Provider Information | |||||||||
| NPI: | 1427194182 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | NICCUM | ||||||||
| FirstName: | TERESA | ||||||||
| MiddleName: | MOORE | ||||||||
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| Credential: | PT | ||||||||
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| Mailing Information | |||||||||
| Address1: | 286 OCEAN AVE | ||||||||
| Address2: | |||||||||
| City: | MONTEREY | ||||||||
| State: | CA | ||||||||
| PostalCode: | 93940 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8312293022 | ||||||||
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| Practice Location | |||||||||
| Address1: | 4560 SE INTERNATIONAL WAY SUITE 100 | ||||||||
| Address2: | CONSONUS HEALTHCARE SERVICES | ||||||||
| City: | MILWAUKIE | ||||||||
| State: | OR | ||||||||
| PostalCode: | 97222 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9712065129 | ||||||||
| FaxNumber: | 9712065209 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/29/2007 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | PT17997 | CA | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
No ID Information.