Provider Demographics
NPI:1477938603
Name:HUSTON, THERESA
Entity Type:Individual
Prefix:
First Name:THERESA
Middle Name:
Last Name:HUSTON
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 1:309 S COLLEGE ST APT 4
Mailing Address - Street 2:
Mailing Address - City:GRANGEVILLE
Mailing Address - State:ID
Mailing Address - Zip Code:83530-2039
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:309 S COLLEGE ST APT 4
Practice Address - Street 2:
Practice Address - City:GRANGEVILLE
Practice Address - State:ID
Practice Address - Zip Code:83530-2039
Practice Address - Country:US
Practice Address - Phone:208-983-0235
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-07-29
Last Update Date:2015-07-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDLPC 5033101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor