Provider Demographics
NPI:1003593799
Name:ENGEBRETSEN, THERESA L
Entity type:Individual
Prefix:
First Name:THERESA
Middle Name:L
Last Name:ENGEBRETSEN
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 1:4575 THOMAS CT
Mailing Address - Street 2:
Mailing Address - City:HOMER
Mailing Address - State:AK
Mailing Address - Zip Code:99603-8226
Mailing Address - Country:US
Mailing Address - Phone:907-399-3525
Mailing Address - Fax:
Practice Address - Street 1:1091 E END RD
Practice Address - Street 2:
Practice Address - City:HOMER
Practice Address - State:AK
Practice Address - Zip Code:99603-7206
Practice Address - Country:US
Practice Address - Phone:907-450-1350
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-07-03
Last Update Date:2023-07-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor