Provider Demographics
NPI:1710422340
Name:CHURCH-NYSTROM, THERESE
Entity Type:Individual
Prefix:
First Name:THERESE
Middle Name:
Last Name:CHURCH-NYSTROM
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 1:20250 N 67TH AVE APT 2162
Mailing Address - Street 2:
Mailing Address - City:GLENDALE
Mailing Address - State:AZ
Mailing Address - Zip Code:85308-6641
Mailing Address - Country:US
Mailing Address - Phone:480-603-5115
Mailing Address - Fax:
Practice Address - Street 1:4545 N 36TH ST STE 125A
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85018-3456
Practice Address - Country:US
Practice Address - Phone:602-224-0202
Practice Address - Fax:602-224-0010
Is Sole Proprietor?:No
Enumeration Date:2017-01-06
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZSLP10414235Z00000X
AZ104142355S0801X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
No2355S0801XSpeech, Language and Hearing Service ProvidersSpecialist/TechnologistSpeech-Language Assistant