Provider Demographics
NPI:1699808436
Name:AVERBECK, THERESA ANN (RD)
Entity Type:Individual
Prefix:
First Name:THERESA
Middle Name:ANN
Last Name:AVERBECK
Suffix:
Gender:F
Credentials:RD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:979 E 3RD ST
Mailing Address - Street 2:SUITE B-1111
Mailing Address - City:CHATTANOOGA
Mailing Address - State:TN
Mailing Address - Zip Code:37403-2136
Mailing Address - Country:US
Mailing Address - Phone:423-778-7036
Mailing Address - Fax:423-778-7832
Practice Address - Street 1:979 E 3RD ST
Practice Address - Street 2:SUITE B-1111
Practice Address - City:CHATTANOOGA
Practice Address - State:TN
Practice Address - Zip Code:37403-2136
Practice Address - Country:US
Practice Address - Phone:423-778-7036
Practice Address - Fax:423-778-7832
Is Sole Proprietor?:No
Enumeration Date:2007-03-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNLDN0000001178133VN1005X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133VN1005XDietary & Nutritional Service ProvidersDietitian, RegisteredNutrition, Renal
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3881168Medicaid
TN3881168Medicare ID - Type Unspecified
TNP82460Medicare UPIN