Basic Information
| Provider Information | |||||||||
| NPI: | 1316368871 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CANTERBUR | ||||||||
| FirstName: | THERESA | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | MRS. | ||||||||
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| Credential: | LBSW | ||||||||
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| Mailing Information | |||||||||
| Address1: | 11886 N SHORE DR | ||||||||
| Address2: | |||||||||
| City: | LAKE | ||||||||
| State: | MI | ||||||||
| PostalCode: | 486329038 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9893395441 | ||||||||
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| Practice Location | |||||||||
| Address1: | 500 S 3RD AVE | ||||||||
| Address2: | |||||||||
| City: | BIG RAPIDS | ||||||||
| State: | MI | ||||||||
| PostalCode: | 493079501 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2317965825 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/30/2013 | ||||||||
| LastUpdateDate: | 12/30/2013 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 104100000X | 6802046130 | MI | Y | Behavioral Health & Social Service Providers | Social Worker |
No ID Information.