Basic Information
| Provider Information | |||||||||
| NPI: | 1871622332 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | SYVERSEN | ||||||||
| FirstName: | TERESA | ||||||||
| MiddleName: | W | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | CADC I | ||||||||
| OtherOrganizationName: | |||||||||
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| OtherLastName: | SYVERSEN | ||||||||
| OtherFirstName: | TERRI | ||||||||
| OtherMiddleName: | W | ||||||||
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| OtherCredential: | CADC I | ||||||||
| OtherLastNameType: | 5 | ||||||||
| Mailing Information | |||||||||
| Address1: | 9875 CHANCE RD | ||||||||
| Address2: | |||||||||
| City: | TILLAMOOK | ||||||||
| State: | OR | ||||||||
| PostalCode: | 97141 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5038428201 | ||||||||
| FaxNumber: | 5038151870 | ||||||||
| Practice Location | |||||||||
| Address1: | 906 MAIN AVE | ||||||||
| Address2: | |||||||||
| City: | TILLAMOOK | ||||||||
| State: | OR | ||||||||
| PostalCode: | 971413816 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5038428201 | ||||||||
| FaxNumber: | 5038151870 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/02/2007 | ||||||||
| LastUpdateDate: | 07/09/2007 | ||||||||
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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 | 101YA0400X | Y | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) |
ID Information
| ID | Type | State | Issuer | Description | 197749 | 05 | OR | MEDICAID |