Provider Demographics
NPI:1639846801
Name:OWENBURG, TERESA (PMHNP-BC)
Entity Type:Individual
Prefix:
First Name:TERESA
Middle Name:
Last Name:OWENBURG
Suffix:
Gender:F
Credentials:PMHNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:50 ROUTE 25A
Mailing Address - Street 2:
Mailing Address - City:SMITHTOWN
Mailing Address - State:NY
Mailing Address - Zip Code:11787-1348
Mailing Address - Country:US
Mailing Address - Phone:631-862-3821
Mailing Address - Fax:
Practice Address - Street 1:50 ROUTE 25A
Practice Address - Street 2:
Practice Address - City:SMITHTOWN
Practice Address - State:NY
Practice Address - Zip Code:11787-1348
Practice Address - Country:US
Practice Address - Phone:631-862-3821
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-08-25
Last Update Date:2022-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYF403594-01363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health