Provider Demographics
NPI:1881990620
Name:POWERS, THERESE MARIE (LAC)
Entity type:Individual
Prefix:
First Name:THERESE
Middle Name:MARIE
Last Name:POWERS
Suffix:
Gender:F
Credentials:LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4251 S HIGUERA ST
Mailing Address - Street 2:#300
Mailing Address - City:SAN LUIS OBISPO
Mailing Address - State:CA
Mailing Address - Zip Code:93401-7700
Mailing Address - Country:US
Mailing Address - Phone:805-748-8885
Mailing Address - Fax:
Practice Address - Street 1:4251 S HIGUERA ST
Practice Address - Street 2:SUITE 300
Practice Address - City:SAN LUIS OBISPO
Practice Address - State:CA
Practice Address - Zip Code:93401-7700
Practice Address - Country:US
Practice Address - Phone:805-748-8885
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-01-26
Last Update Date:2014-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA13997171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist