Provider Demographics
NPI:1467151217
Name:PAWLETKOO, TERESA
Entity Type:Individual
Prefix:
First Name:TERESA
Middle Name:
Last Name:PAWLETKOO
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 1:110 STARBIRD RD # 7
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:ME
Mailing Address - Zip Code:04102-1758
Mailing Address - Country:US
Mailing Address - Phone:603-396-1645
Mailing Address - Fax:
Practice Address - Street 1:110 STARBIRD RD # 7
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:ME
Practice Address - Zip Code:04102-1758
Practice Address - Country:US
Practice Address - Phone:603-396-1645
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-03-01
Last Update Date:2023-03-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MEPS1303103TS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchool