Provider Demographics
NPI:1164899779
Name:STANABACK, TERESA (OTR)
Entity Type:Individual
Prefix:
First Name:TERESA
Middle Name:
Last Name:STANABACK
Suffix:
Gender:F
Credentials:OTR
Other - Prefix:
Other - First Name:TERRI
Other - Middle Name:
Other - Last Name:STANABACK
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:OTR
Mailing Address - Street 1:10905 NE 48TH ST
Mailing Address - Street 2:
Mailing Address - City:KIRKLAND
Mailing Address - State:WA
Mailing Address - Zip Code:98033-7704
Mailing Address - Country:US
Mailing Address - Phone:409-392-1105
Mailing Address - Fax:
Practice Address - Street 1:9441 LBJ FREEWAY
Practice Address - Street 2:SUITE 602
Practice Address - City:DALLAS,
Practice Address - State:TX
Practice Address - Zip Code:75243
Practice Address - Country:US
Practice Address - Phone:469-249-1883
Practice Address - Fax:887-778-7505
Is Sole Proprietor?:Yes
Enumeration Date:2015-08-31
Last Update Date:2015-08-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX110025225XP0019X
WAOT60579322225XP0019X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225XP0019XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistPhysical Rehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX110025OtherECPTOTE
WAOT 60579322OtherWASHINGTON STATE DEPARTMENT OF HEALTH