Provider Demographics
NPI:1356110068
Name:MACDONALD, THERESA
Entity type:Individual
Prefix:
First Name:THERESA
Middle Name:
Last Name:MACDONALD
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 1:1633 CONCORD ST
Mailing Address - Street 2:
Mailing Address - City:DUNEDIN
Mailing Address - State:FL
Mailing Address - Zip Code:34698-6312
Mailing Address - Country:US
Mailing Address - Phone:727-269-1689
Mailing Address - Fax:
Practice Address - Street 1:1633 CONCORD ST
Practice Address - Street 2:
Practice Address - City:DUNEDIN
Practice Address - State:FL
Practice Address - Zip Code:34698-6312
Practice Address - Country:US
Practice Address - Phone:727-269-1689
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-12-21
Last Update Date:2023-12-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician