Provider Demographics
NPI:1750748943
Name:ROMAINE, THERESA MICHELLE
Entity type:Individual
Prefix:MISS
First Name:THERESA
Middle Name:MICHELLE
Last Name:ROMAINE
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 1:24 IMOGENE DR
Mailing Address - Street 2:
Mailing Address - City:MASSAPEQUA
Mailing Address - State:NY
Mailing Address - Zip Code:11758-1010
Mailing Address - Country:US
Mailing Address - Phone:516-236-1892
Mailing Address - Fax:
Practice Address - Street 1:24 IMOGENE DR
Practice Address - Street 2:
Practice Address - City:MASSAPEQUA
Practice Address - State:NY
Practice Address - Zip Code:11758-1010
Practice Address - Country:US
Practice Address - Phone:516-236-1892
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-01-20
Last Update Date:2016-01-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst