Provider Demographics
NPI:1497958219
Name:HAHN, THERESE MINJARES (PHD, OMD, LAC)
Entity Type:Individual
Prefix:
First Name:THERESE
Middle Name:MINJARES
Last Name:HAHN
Suffix:
Gender:F
Credentials:PHD, OMD, LAC
Other - Prefix:
Other - First Name:THERESE
Other - Middle Name:ANNE
Other - Last Name:MINJARES
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LAC
Mailing Address - Street 1:P. O. BOX 341
Mailing Address - Street 2:
Mailing Address - City:COCOLALLA
Mailing Address - State:ID
Mailing Address - Zip Code:83813
Mailing Address - Country:US
Mailing Address - Phone:208-683-5211
Mailing Address - Fax:
Practice Address - Street 1:1405 LITTLE BLACKTAIL ROAD
Practice Address - Street 2:
Practice Address - City:CAREYWOOD
Practice Address - State:ID
Practice Address - Zip Code:83809
Practice Address - Country:US
Practice Address - Phone:208-683-5211
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-06-08
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDACU3171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist