Provider Demographics
NPI:1891316550
Name:SISTRUNK, TERESA MARIE (RBT)
Entity type:Individual
Prefix:
First Name:TERESA
Middle Name:MARIE
Last Name:SISTRUNK
Suffix:
Gender:F
Credentials:RBT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3800 UNIVERSITY AVE
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:GA
Mailing Address - Zip Code:31907-5609
Mailing Address - Country:US
Mailing Address - Phone:800-676-5130
Mailing Address - Fax:888-959-5753
Practice Address - Street 1:3800 UNIVERSITY AVE
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:GA
Practice Address - Zip Code:31907-5609
Practice Address - Country:US
Practice Address - Phone:800-676-5130
Practice Address - Fax:888-959-5753
Is Sole Proprietor?:Yes
Enumeration Date:2020-05-04
Last Update Date:2020-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARBT20-116504106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior TechnicianGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GARBT20-116504OtherREGISTERED BEHAVIORAL TECHNICIAN