Provider Demographics
NPI:1699470260
Name:ESPINOSA, THERESA R
Entity type:Individual
Prefix:
First Name:THERESA
Middle Name:R
Last Name:ESPINOSA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:521 6TH ST
Mailing Address - Street 2:
Mailing Address - City:MAXWELL
Mailing Address - State:IA
Mailing Address - Zip Code:50161-7711
Mailing Address - Country:US
Mailing Address - Phone:515-460-2375
Mailing Address - Fax:
Practice Address - Street 1:1619 S HIGH AVE
Practice Address - Street 2:
Practice Address - City:AMES
Practice Address - State:IA
Practice Address - Zip Code:50010-8055
Practice Address - Country:US
Practice Address - Phone:515-232-3206
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-04-03
Last Update Date:2023-05-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA119205101YM0800X
IAT22175101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health