Provider Demographics
NPI:1710604863
Name:SPACE, THEREASA (PA(ASCP))
Entity Type:Individual
Prefix:
First Name:THEREASA
Middle Name:
Last Name:SPACE
Suffix:
Gender:F
Credentials:PA(ASCP)
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2417 INDIANA AVE
Mailing Address - Street 2:
Mailing Address - City:LANSING
Mailing Address - State:IL
Mailing Address - Zip Code:60438
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:901 MACARTHUR BLVD
Practice Address - Street 2:
Practice Address - City:MUNSTER
Practice Address - State:IN
Practice Address - Zip Code:46321-2901
Practice Address - Country:US
Practice Address - Phone:219-703-1784
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-10-19
Last Update Date:2022-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes246Q00000XTechnologists, Technicians & Other Technical Service ProvidersSpecialist/Technologist, Pathology