Provider Demographics
NPI:1043262413
Name:VIRSIK, THERESA AILEEN (RD, CDE)
Entity type:Individual
Prefix:MRS
First Name:THERESA
Middle Name:AILEEN
Last Name:VIRSIK
Suffix:
Gender:
Credentials:RD, CDE
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 60447
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28260-0447
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2225 FREEDOM DR
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28208-1000
Practice Address - Country:US
Practice Address - Phone:704-384-7390
Practice Address - Fax:704-384-5669
Is Sole Proprietor?:No
Enumeration Date:2006-05-16
Last Update Date:2025-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL864112133V00000X
NCL008189133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered