Provider Demographics
NPI:1427548221
Name:SLACK, TERESA LEE V (MA)
Entity Type:Individual
Prefix:MS
First Name:TERESA
Middle Name:LEE
Last Name:SLACK
Suffix:V
Gender:F
Credentials:MA
Other - Prefix:
Other - First Name:TERESA
Other - Middle Name:LEE
Other - Last Name:WIBBELSMAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1300 N 17TH AVE
Mailing Address - Street 2:
Mailing Address - City:GREELEY
Mailing Address - State:CO
Mailing Address - Zip Code:80631-9584
Mailing Address - Country:US
Mailing Address - Phone:970-347-2120
Mailing Address - Fax:
Practice Address - Street 1:928 12TH ST
Practice Address - Street 2:
Practice Address - City:GREELEY
Practice Address - State:CO
Practice Address - Zip Code:80631-4024
Practice Address - Country:US
Practice Address - Phone:970-347-2120
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-05-16
Last Update Date:2018-05-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175T00000XOther Service ProvidersPeer Specialist