Provider Demographics
NPI:1043685084
Name:AMBERG, TERESA (LMP)
Entity Type:Individual
Prefix:
First Name:TERESA
Middle Name:
Last Name:AMBERG
Suffix:
Gender:F
Credentials:LMP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15003 NE 70TH ST
Mailing Address - Street 2:
Mailing Address - City:VANCOUVER
Mailing Address - State:WA
Mailing Address - Zip Code:98682-3839
Mailing Address - Country:US
Mailing Address - Phone:360-356-8155
Mailing Address - Fax:
Practice Address - Street 1:1104 MAIN ST
Practice Address - Street 2:550F
Practice Address - City:VANCOUVER
Practice Address - State:WA
Practice Address - Zip Code:98660-2999
Practice Address - Country:US
Practice Address - Phone:360-356-8155
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-12-02
Last Update Date:2015-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA60614537225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist