Provider Demographics
NPI:1831714138
Name:NOWAK, THERESA MARIE (PHD)
Entity type:Individual
Prefix:DR
First Name:THERESA
Middle Name:MARIE
Last Name:NOWAK
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 1:233 LARCH LN
Mailing Address - Street 2:
Mailing Address - City:LEXINGTON
Mailing Address - State:KY
Mailing Address - Zip Code:40511-2006
Mailing Address - Country:US
Mailing Address - Phone:859-351-6471
Mailing Address - Fax:
Practice Address - Street 1:233 LARCH LN
Practice Address - Street 2:
Practice Address - City:LEXINGTON
Practice Address - State:KY
Practice Address - Zip Code:40511-2006
Practice Address - Country:US
Practice Address - Phone:859-351-6471
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-06-11
Last Update Date:2020-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY128999103TS0200X, 103TC2200X, 103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
No103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchool
No103TC2200XBehavioral Health & Social Service ProvidersPsychologistClinical Child & Adolescent