Provider Demographics
NPI:1972976033
Name:NYBLOM, TERI X (COTA/L)
Entity Type:Individual
Prefix:
First Name:TERI
Middle Name:
Last Name:NYBLOM
Suffix:X
Gender:F
Credentials:COTA/L
Other - Prefix:
Other - First Name:TERI
Other - Middle Name:
Other - Last Name:NYBLOM
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:COTA/L
Mailing Address - Street 1:9916 62ND AVENUE CT E
Mailing Address - Street 2:
Mailing Address - City:PUYALLUP
Mailing Address - State:WA
Mailing Address - Zip Code:98373-4174
Mailing Address - Country:US
Mailing Address - Phone:253-226-0217
Mailing Address - Fax:253-848-4269
Practice Address - Street 1:2830 I ST NE
Practice Address - Street 2:
Practice Address - City:AUBURN
Practice Address - State:WA
Practice Address - Zip Code:98002-2410
Practice Address - Country:US
Practice Address - Phone:253-394-0844
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-11-10
Last Update Date:2015-11-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAOC 60601017224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant