Provider Demographics
NPI:1477671436
Name:MCDERMOTT, THERESA A (DC, ND)
Entity Type:Individual
Prefix:
First Name:THERESA
Middle Name:A
Last Name:MCDERMOTT
Suffix:
Gender:F
Credentials:DC, ND
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:19300 SW BOONES FERRY RD
Mailing Address - Street 2:STE D
Mailing Address - City:TUALATIN
Mailing Address - State:OR
Mailing Address - Zip Code:97062-9086
Mailing Address - Country:US
Mailing Address - Phone:503-692-1995
Mailing Address - Fax:503-692-7212
Practice Address - Street 1:19300 SW BOONES FERRY RD
Practice Address - Street 2:STE D
Practice Address - City:TUALATIN
Practice Address - State:OR
Practice Address - Zip Code:97062-9086
Practice Address - Country:US
Practice Address - Phone:503-692-1995
Practice Address - Fax:503-692-7212
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-27
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR272989111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR115865Medicare ID - Type Unspecified