Provider Demographics
NPI:1720687163
Name:TRUMP, THERESA A (MS ED)
Entity Type:Individual
Prefix:
First Name:THERESA
Middle Name:A
Last Name:TRUMP
Suffix:
Gender:F
Credentials:MS ED
Other - Prefix:
Other - First Name:THERESA
Other - Middle Name:A
Other - Last Name:GRATTAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MS ED
Mailing Address - Street 1:7 MAPLELINE RD
Mailing Address - Street 2:
Mailing Address - City:BALLSTON LAKE
Mailing Address - State:NY
Mailing Address - Zip Code:12019-1589
Mailing Address - Country:US
Mailing Address - Phone:518-368-2607
Mailing Address - Fax:
Practice Address - Street 1:7 MAPLELINE RD
Practice Address - Street 2:
Practice Address - City:BALLSTON LAKE
Practice Address - State:NY
Practice Address - Zip Code:12019-1589
Practice Address - Country:US
Practice Address - Phone:518-368-2607
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-10-17
Last Update Date:2022-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
2255A2300X
NY174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
No2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer