Provider Demographics
NPI:1023200508
Name:INTORCIA, TERESA Y (MNT)
Entity Type:Individual
Prefix:
First Name:TERESA
Middle Name:Y
Last Name:INTORCIA
Suffix:
Gender:F
Credentials:MNT
Other - Prefix:
Other - First Name:TERESA
Other - Middle Name:Y
Other - Last Name:INTORCIA
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:RD,MNT
Mailing Address - Street 1:830 WASHINGTON ST
Mailing Address - Street 2:
Mailing Address - City:WATERTOWN
Mailing Address - State:NY
Mailing Address - Zip Code:13601-4034
Mailing Address - Country:US
Mailing Address - Phone:315-785-5293
Mailing Address - Fax:
Practice Address - Street 1:1001 WEST ST
Practice Address - Street 2:
Practice Address - City:CARTHAGE
Practice Address - State:NY
Practice Address - Zip Code:13619-9703
Practice Address - Country:US
Practice Address - Phone:315-493-1005
Practice Address - Fax:315-493-0038
Is Sole Proprietor?:No
Enumeration Date:2007-08-17
Last Update Date:2017-05-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY002834133VN1006X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133VN1006XDietary & Nutritional Service ProvidersDietitian, RegisteredNutrition, Metabolic
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYDD1086Medicare PIN