Provider Demographics
NPI:1184956302
Name:IVERSON, TERESA J
Entity type:Individual
Prefix:MS
First Name:TERESA
Middle Name:J
Last Name:IVERSON
Suffix:
Gender:F
Credentials:
Other - Prefix:MR
Other - First Name:TERESA
Other - Middle Name:J
Other - Last Name:IVERSON
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:LMT
Mailing Address - Street 1:2034 10TH AVE
Mailing Address - Street 2:2034 10TH AVE LONGVIEW, WA. 98632
Mailing Address - City:LONGVIEW
Mailing Address - State:WA
Mailing Address - Zip Code:98632-4007
Mailing Address - Country:US
Mailing Address - Phone:503-481-0289
Mailing Address - Fax:
Practice Address - Street 1:2034 10TH AVE
Practice Address - Street 2:2034 10TH AVE LONGVIEW, WA. 98632
Practice Address - City:LONGVIEW
Practice Address - State:WA
Practice Address - Zip Code:98632-4007
Practice Address - Country:US
Practice Address - Phone:503-481-0289
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-02-12
Last Update Date:2010-02-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA00014211225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist