Provider Demographics
NPI:1447617055
Name:HAWORTH, THERESA I
Entity Type:Individual
Prefix:
First Name:THERESA
Middle Name:I
Last Name:HAWORTH
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:320 CENTRAL AVE
Mailing Address - Street 2:SUITE 406
Mailing Address - City:COOS BAY
Mailing Address - State:OR
Mailing Address - Zip Code:97420-2272
Mailing Address - Country:US
Mailing Address - Phone:541-269-0321
Mailing Address - Fax:
Practice Address - Street 1:62754 KARL ROAD
Practice Address - Street 2:
Practice Address - City:COOS BAY
Practice Address - State:OR
Practice Address - Zip Code:97420
Practice Address - Country:US
Practice Address - Phone:541-269-2813
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-01-27
Last Update Date:2016-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR500400418Medicaid