Provider Demographics
NPI:1154481935
Name:WRIGHT, THERESA ROSE (PHD)
Entity Type:Individual
Prefix:DR
First Name:THERESA
Middle Name:ROSE
Last Name:WRIGHT
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:45 SANDHURST DRIVE
Mailing Address - Street 2:
Mailing Address - City:MOUNT LAUREL
Mailing Address - State:NJ
Mailing Address - Zip Code:08054-1151
Mailing Address - Country:US
Mailing Address - Phone:609-504-4118
Mailing Address - Fax:
Practice Address - Street 1:3747 CHURCH RD
Practice Address - Street 2:SUITE 100
Practice Address - City:MOUNT LAUREL
Practice Address - State:NJ
Practice Address - Zip Code:08054-1144
Practice Address - Country:US
Practice Address - Phone:609-504-4118
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-11
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ35S100409400103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ0050130Medicaid
NJ0050130Medicaid