Provider Demographics
NPI:1659728426
Name:POLLARD, THERESA
Entity Type:Individual
Prefix:
First Name:THERESA
Middle Name:
Last Name:POLLARD
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 1:4732 RIVER RD
Mailing Address - Street 2:
Mailing Address - City:BUHL
Mailing Address - State:ID
Mailing Address - Zip Code:83316-5103
Mailing Address - Country:US
Mailing Address - Phone:208-308-9373
Mailing Address - Fax:
Practice Address - Street 1:4732 RIVER RD
Practice Address - Street 2:
Practice Address - City:BUHL
Practice Address - State:ID
Practice Address - Zip Code:83316-5103
Practice Address - Country:US
Practice Address - Phone:208-308-9373
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-05-20
Last Update Date:2016-05-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDMASG-329225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist