Provider Demographics
NPI:1790127058
Name:AUDET-SHILINGA, THERESE (MT)
Entity Type:Individual
Prefix:
First Name:THERESE
Middle Name:
Last Name:AUDET-SHILINGA
Suffix:
Gender:F
Credentials:MT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1001 FARMINGTON AVE
Mailing Address - Street 2:SUITE 101
Mailing Address - City:BRISTOL
Mailing Address - State:CT
Mailing Address - Zip Code:06010-3990
Mailing Address - Country:US
Mailing Address - Phone:860-582-8024
Mailing Address - Fax:860-585-0609
Practice Address - Street 1:1001 FARMINGTON AVE
Practice Address - Street 2:SUITE 101
Practice Address - City:BRISTOL
Practice Address - State:CT
Practice Address - Zip Code:06010-3990
Practice Address - Country:US
Practice Address - Phone:860-582-8024
Practice Address - Fax:860-585-0609
Is Sole Proprietor?:No
Enumeration Date:2013-07-26
Last Update Date:2013-07-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT002114225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist