=====================================================
General NPI Number Information
=====================================================
NPI Number | 1275040545
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | THERESA MARSHALL ND
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/08/2018
-----------------------------------------------------
Last Update Date | 01/08/2018
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 800 W IVY ST STE A
-----------------------------------------------------
City | SAN DIEGO
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92101-1771
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 858-997-4100
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 5 CLARK CT
-----------------------------------------------------
City | BRIDGEWATER
-----------------------------------------------------
State | NJ
-----------------------------------------------------
Zip | 08807-3073
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 732-693-1042
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 175F00000X
-----------------------------------------------------
Taxonomy Name | Naturopath
-----------------------------------------------------
License Number | 956
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------