Provider Demographics
NPI:1316377708
Name:TERBECK, SALLY (CN)
Entity Type:Individual
Prefix:
First Name:SALLY
Middle Name:
Last Name:TERBECK
Suffix:
Gender:F
Credentials:CN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1010 N 45TH ST
Mailing Address - Street 2:#4
Mailing Address - City:SEATTLE
Mailing Address - State:WA
Mailing Address - Zip Code:98103-6672
Mailing Address - Country:US
Mailing Address - Phone:206-850-8230
Mailing Address - Fax:
Practice Address - Street 1:1904 3RD AVE
Practice Address - Street 2:STE. 918
Practice Address - City:SEATTLE
Practice Address - State:WA
Practice Address - Zip Code:98101-1126
Practice Address - Country:US
Practice Address - Phone:206-431-0138
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-11-20
Last Update Date:2013-11-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WANU 60417976133N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133N00000XDietary & Nutritional Service ProvidersNutritionist