Healthcare Provider Details

I. General information

NPI: 1063654754
Provider Name (Legal Business Name): THERESE STORINO WATERHOUS RD, LD, PHD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/27/2009
Last Update Date: 09/22/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

744 NW 4TH ST
CORVALLIS OR
97330-6415
US

IV. Provider business mailing address

744 NW 4TH ST
CORVALLIS OR
97330-6415
US

V. Phone/Fax

Practice location:
  • Phone: 541-207-7205
  • Fax: 877-840-1725
Mailing address:
  • Phone: 541-207-7205
  • Fax: 877-840-1725

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number371
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: