Provider Demographics
NPI:1174181093
Name:GARBO, THERESA MARIE (MED)
Entity Type:Individual
Prefix:
First Name:THERESA
Middle Name:MARIE
Last Name:GARBO
Suffix:
Gender:F
Credentials:MED
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9666 OLIVE BLVD
Mailing Address - Street 2:
Mailing Address - City:OLIVETTE
Mailing Address - State:MO
Mailing Address - Zip Code:63132-3013
Mailing Address - Country:US
Mailing Address - Phone:314-787-5100
Mailing Address - Fax:
Practice Address - Street 1:9666 OLIVE BLVD
Practice Address - Street 2:
Practice Address - City:OLIVETTE
Practice Address - State:MO
Practice Address - Zip Code:63132-3013
Practice Address - Country:US
Practice Address - Phone:314-787-5100
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-06-05
Last Update Date:2019-06-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO000791101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional