Healthcare Provider Details

I. General information

NPI: 1245354174
Provider Name (Legal Business Name): YVONNE PATRICIA TEVERBAUGH PHD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/17/2007
Last Update Date: 07/07/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3208 STAMM AVE
INDIANAPOLIS IN
46240-3537
US

IV. Provider business mailing address

3208 STAMM AVE
INDIANAPOLIS IN
46240-3537
US

V. Phone/Fax

Practice location:
  • Phone: 317-253-3520
  • Fax:
Mailing address:
  • Phone: 317-253-3520
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code133N00000X
TaxonomyNutritionist
License NumberUNIV OF CALIFORNA
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code133NN1002X
TaxonomyNutrition Education Nutritionist
License Number
License Number StateNULL
# 3
Primary TaxonomyN
Taxonomy Code175F00000X
TaxonomyNaturopath
License NumberNONE NECESSARY
License Number StateCA
# 4
Primary TaxonomyN
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License NumberNONE NECESSARY
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: