Provider Demographics
NPI:1720423650
Name:BUYSSE, THERESA MARIE (PHD)
Entity Type:Individual
Prefix:DR
First Name:THERESA
Middle Name:MARIE
Last Name:BUYSSE
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:20111 83RD AVE W
Mailing Address - Street 2:
Mailing Address - City:EDMONDS
Mailing Address - State:WA
Mailing Address - Zip Code:98026-6727
Mailing Address - Country:US
Mailing Address - Phone:425-775-4059
Mailing Address - Fax:
Practice Address - Street 1:3931 COLBY AVE
Practice Address - Street 2:
Practice Address - City:EVERETT
Practice Address - State:WA
Practice Address - Zip Code:98201-4926
Practice Address - Country:US
Practice Address - Phone:425-249-9618
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-05-06
Last Update Date:2016-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPY00003706103T00000X, 103TC2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
No103TC2200XBehavioral Health & Social Service ProvidersPsychologistClinical Child & Adolescent