Provider Demographics
NPI:1689715658
Name:KOHLENBERG, TERESA M (MD)
Entity Type:Individual
Prefix:DR
First Name:TERESA
Middle Name:M
Last Name:KOHLENBERG
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:93 GARFIELD ST
Mailing Address - Street 2:
Mailing Address - City:WATERTOWN
Mailing Address - State:MA
Mailing Address - Zip Code:02472-4914
Mailing Address - Country:US
Mailing Address - Phone:617-642-1494
Mailing Address - Fax:
Practice Address - Street 1:93 GARFIELD ST
Practice Address - Street 2:
Practice Address - City:WATERTOWN
Practice Address - State:MA
Practice Address - Zip Code:02472-4914
Practice Address - Country:US
Practice Address - Phone:617-642-1494
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-02-10
Last Update Date:2007-07-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA56098208000000X, 2084P0804X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
No2084P0804XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyChild & Adolescent Psychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
MAD88426Medicare UPIN