Basic Information
| Provider Information | |||||||||
| NPI: | 1063503456 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | FOSTER | ||||||||
| FirstName: | THERESA | ||||||||
| MiddleName: | M | ||||||||
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| Credential: | MP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1917 N LAKEWOOD DR | ||||||||
| Address2: | |||||||||
| City: | COEUR D ALENE | ||||||||
| State: | ID | ||||||||
| PostalCode: | 838142634 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2086648194 | ||||||||
| FaxNumber: | 2086671847 | ||||||||
| Practice Location | |||||||||
| Address1: | 1101 E POLSTON AVE | ||||||||
| Address2: | SUITE A | ||||||||
| City: | POST FALLS | ||||||||
| State: | ID | ||||||||
| PostalCode: | 838546045 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2087738111 | ||||||||
| FaxNumber: | 2087738385 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/28/2006 | ||||||||
| LastUpdateDate: | 08/11/2009 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225700000X | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Massage Therapist |
ID Information
| ID | Type | State | Issuer | Description | 0210660 | 01 | WA | WASH ST LABOR & INDUSTRY | OTHER |