Provider Demographics
NPI:1043723117
Name:WHITE, THERESE BEUTEL (MS)
Entity Type:Individual
Prefix:
First Name:THERESE
Middle Name:BEUTEL
Last Name:WHITE
Suffix:
Gender:F
Credentials:MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3245 RICHMOND AVE
Mailing Address - Street 2:
Mailing Address - City:SHOREVIEW
Mailing Address - State:MN
Mailing Address - Zip Code:55126-3834
Mailing Address - Country:US
Mailing Address - Phone:651-262-8303
Mailing Address - Fax:
Practice Address - Street 1:1660 COUNTY ROAD B W
Practice Address - Street 2:
Practice Address - City:ROSEVILLE
Practice Address - State:MN
Practice Address - Zip Code:55113-4033
Practice Address - Country:US
Practice Address - Phone:651-639-2535
Practice Address - Fax:651-639-1996
Is Sole Proprietor?:Yes
Enumeration Date:2017-11-13
Last Update Date:2017-11-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN5529261QH0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QH0700XAmbulatory Health Care FacilitiesClinic/CenterHearing and Speech