Provider Demographics
NPI:1902530918
Name:DAMBROSE, THERESA
Entity Type:Individual
Prefix:
First Name:THERESA
Middle Name:
Last Name:DAMBROSE
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 1:1931 W WOLFRAM ST
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60657-4031
Mailing Address - Country:US
Mailing Address - Phone:312-375-6068
Mailing Address - Fax:
Practice Address - Street 1:1931 W WOLFRAM ST
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60657-4031
Practice Address - Country:US
Practice Address - Phone:312-375-6068
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-07-14
Last Update Date:2022-07-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175F00000XOther Service ProvidersNaturopath