Provider Demographics
NPI:1669601514
Name:KEARNS, THERESA STACY (PSY D)
Entity type:Individual
Prefix:DR
First Name:THERESA
Middle Name:STACY
Last Name:KEARNS
Suffix:
Gender:F
Credentials:PSY D
Other - Prefix:DR
Other - First Name:THERESA
Other - Middle Name:STACY
Other - Last Name:KEARNS-COOPER
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:PSYD
Mailing Address - Street 1:6000 KANAKANAK ROAD
Mailing Address - Street 2:PO BOX 130
Mailing Address - City:DILLINGHAM
Mailing Address - State:AK
Mailing Address - Zip Code:99576
Mailing Address - Country:US
Mailing Address - Phone:907-842-1230
Mailing Address - Fax:907-842-5174
Practice Address - Street 1:6000 KANAKANAK ROAD
Practice Address - Street 2:
Practice Address - City:DILLINGHAM
Practice Address - State:AK
Practice Address - Zip Code:99576
Practice Address - Country:US
Practice Address - Phone:907-842-1230
Practice Address - Fax:907-842-5174
Is Sole Proprietor?:No
Enumeration Date:2009-07-13
Last Update Date:2009-07-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS00000LICENSE ELIGIBL103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical