Provider Demographics
NPI:1538440821
Name:PORCARELLI, THERESA A (RDMS, RVT, RDCS)
Entity type:Individual
Prefix:
First Name:THERESA
Middle Name:A
Last Name:PORCARELLI
Suffix:
Gender:F
Credentials:RDMS, RVT, RDCS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:807 W LAKESHORE DR
Mailing Address - Street 2:
Mailing Address - City:COEUR D ALENE
Mailing Address - State:ID
Mailing Address - Zip Code:83814-2131
Mailing Address - Country:US
Mailing Address - Phone:208-661-2366
Mailing Address - Fax:
Practice Address - Street 1:1076 W HAYDEN AVE
Practice Address - Street 2:
Practice Address - City:HAYDEN
Practice Address - State:ID
Practice Address - Zip Code:83835-8793
Practice Address - Country:US
Practice Address - Phone:208-772-2823
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-08-31
Last Update Date:2011-08-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD30822471S1302X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2471S1302XTechnologists, Technicians & Other Technical Service ProvidersRadiologic TechnologistSonography