Provider Demographics
NPI:1124301429
Name:PIQUE, TEODOLINDA WAYSHAK (PSYD)
Entity type:Individual
Prefix:DR
First Name:TEODOLINDA
Middle Name:WAYSHAK
Last Name:PIQUE
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:35 RIVERWALK WAY UNIT 108
Mailing Address - Street 2:
Mailing Address - City:LOWELL
Mailing Address - State:MA
Mailing Address - Zip Code:01854-3651
Mailing Address - Country:US
Mailing Address - Phone:510-332-1819
Mailing Address - Fax:
Practice Address - Street 1:100 MERRIMACK ST
Practice Address - Street 2:SUITE 205-F
Practice Address - City:LOWELL
Practice Address - State:MA
Practice Address - Zip Code:01852-1708
Practice Address - Country:US
Practice Address - Phone:510-332-1819
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-09-22
Last Update Date:2019-03-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA9449103T00000X, 103TC0700X
CAPSY19127103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No103T00000XBehavioral Health & Social Service ProvidersPsychologist