Provider Demographics
NPI:1043262413
Name:VIRSIK, THERESA AILEEN (RD, CDE)
Entity Type:Individual
Prefix:MRS
First Name:THERESA
Middle Name:AILEEN
Last Name:VIRSIK
Suffix:
Gender:F
Credentials:RD, CDE
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5054 PINOT ST
Mailing Address - Street 2:
Mailing Address - City:ROCKLEDGE
Mailing Address - State:FL
Mailing Address - Zip Code:32955-5167
Mailing Address - Country:US
Mailing Address - Phone:321-433-8060
Mailing Address - Fax:
Practice Address - Street 1:BREVARD VA OUTPATIENT CLINIC
Practice Address - Street 2:2900 VETERANS WAY
Practice Address - City:MELBOURNE
Practice Address - State:FL
Practice Address - Zip Code:32940
Practice Address - Country:US
Practice Address - Phone:321-637-3788
Practice Address - Fax:321-637-3648
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-05-16
Last Update Date:2023-09-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL864112133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered