Provider Demographics
NPI:1578307989
Name:DILBERT, TERESA
Entity type:Individual
Prefix:
First Name:TERESA
Middle Name:
Last Name:DILBERT
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 1:540 NW 4TH AVE APT 1805
Mailing Address - Street 2:
Mailing Address - City:FT LAUDERDALE
Mailing Address - State:FL
Mailing Address - Zip Code:33311-8180
Mailing Address - Country:US
Mailing Address - Phone:954-210-2510
Mailing Address - Fax:
Practice Address - Street 1:540 NW 4TH AVE APT 1805
Practice Address - Street 2:
Practice Address - City:FT LAUDERDALE
Practice Address - State:FL
Practice Address - Zip Code:33311-8180
Practice Address - Country:US
Practice Address - Phone:954-210-2510
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-06-20
Last Update Date:2024-07-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLBACB965772106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
No106S00000XBehavioral Health & Social Service ProvidersBehavior Technician