Provider Demographics
NPI:1770626681
Name:STOCKWELL, TERI L (DC)
Entity type:Individual
Prefix:
First Name:TERI
Middle Name:L
Last Name:STOCKWELL
Suffix:
Gender:F
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1415 BARCLAY CIR SE
Mailing Address - Street 2:
Mailing Address - City:MARIETTA
Mailing Address - State:GA
Mailing Address - Zip Code:30060-2943
Mailing Address - Country:US
Mailing Address - Phone:770-426-2786
Mailing Address - Fax:770-792-6113
Practice Address - Street 1:1415 BARCLAY CIR SE
Practice Address - Street 2:
Practice Address - City:MARIETTA
Practice Address - State:GA
Practice Address - Zip Code:30060-2943
Practice Address - Country:US
Practice Address - Phone:770-426-2786
Practice Address - Fax:770-792-6113
Is Sole Proprietor?:No
Enumeration Date:2007-02-14
Last Update Date:2021-04-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GACHIR009030111N00000X
MI2301007022111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIP101464OtherBCN INDIVIDUAL PIN NUMBER
MI950B810180OtherBCBS GROUP NUMBER
MI950B852340OtherBCBS INDIVIDUAL ID NUMBER
MI3144040Medicaid
MIG05544OtherBCN GROUP NUMBER