Provider Demographics
NPI:1184406613
Name:DATTOLO, THERESE (DTCM, LAC)
Entity type:Individual
Prefix:
First Name:THERESE
Middle Name:
Last Name:DATTOLO
Suffix:
Gender:F
Credentials:DTCM, LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5372 EAGLE LAKE DR
Mailing Address - Street 2:
Mailing Address - City:PALM BEACH GARDENS
Mailing Address - State:FL
Mailing Address - Zip Code:33418-1540
Mailing Address - Country:US
Mailing Address - Phone:732-685-2781
Mailing Address - Fax:
Practice Address - Street 1:103 S US HIGHWAY 1 STE B4
Practice Address - Street 2:
Practice Address - City:JUPITER
Practice Address - State:FL
Practice Address - Zip Code:33477-5101
Practice Address - Country:US
Practice Address - Phone:561-406-6905
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-10-18
Last Update Date:2023-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL4446171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist