Healthcare Provider Details

I. General information

NPI: 1063619112
Provider Name (Legal Business Name): TERESA BRUCKER SPIRK RD, CDE, LDN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/02/2007
Last Update Date: 01/07/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

977 PERRY HWY
PITTSBURGH PA
15237-2172
US

IV. Provider business mailing address

12311 PERRY HWY
WEXFORD PA
15090-8344
US

V. Phone/Fax

Practice location:
  • Phone: 412-266-1079
  • Fax:
Mailing address:
  • Phone: 412-266-1079
  • Fax: 412-630-0132

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133VN1006X
TaxonomyMetabolic Nutrition Registered Dietitian
License NumberDN000776
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: