Provider Demographics
NPI:1063654754
Name:WATERHOUS, THERESE STORINO (RD, LD, PHD)
Entity Type:Individual
Prefix:DR
First Name:THERESE
Middle Name:STORINO
Last Name:WATERHOUS
Suffix:
Gender:F
Credentials:RD, LD, PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:744 NW 4TH ST
Mailing Address - Street 2:
Mailing Address - City:CORVALLIS
Mailing Address - State:OR
Mailing Address - Zip Code:97330-6415
Mailing Address - Country:US
Mailing Address - Phone:541-207-7205
Mailing Address - Fax:877-840-1725
Practice Address - Street 1:744 NW 4TH ST
Practice Address - Street 2:
Practice Address - City:CORVALLIS
Practice Address - State:OR
Practice Address - Zip Code:97330-6415
Practice Address - Country:US
Practice Address - Phone:541-207-7205
Practice Address - Fax:877-840-1725
Is Sole Proprietor?:Yes
Enumeration Date:2009-03-27
Last Update Date:2015-09-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR371133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR500627442Medicaid