Provider Demographics
NPI:1922486315
Name:GROTKOPP, TERESA (LAC)
Entity Type:Individual
Prefix:
First Name:TERESA
Middle Name:
Last Name:GROTKOPP
Suffix:
Gender:F
Credentials:LAC
Other - Prefix:
Other - First Name:TERESA
Other - Middle Name:
Other - Last Name:AYRES
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:SEESTR. 18
Mailing Address - Street 2:
Mailing Address - City:HAMBURG
Mailing Address - State:HAMBURG
Mailing Address - Zip Code:22607
Mailing Address - Country:DE
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1221 NOBLE ST
Practice Address - Street 2:
Practice Address - City:FAIRBANKS
Practice Address - State:AK
Practice Address - Zip Code:99701-4979
Practice Address - Country:US
Practice Address - Phone:907-456-4234
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-05-18
Last Update Date:2015-07-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
HIACU-160171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist