Provider Demographics
NPI:1538606173
Name:WELT, THERESA
Entity type:Individual
Prefix:
First Name:THERESA
Middle Name:
Last Name:WELT
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:PO BOX 20267
Mailing Address - Street 2:
Mailing Address - City:FERNDALE
Mailing Address - State:MI
Mailing Address - Zip Code:48220-0267
Mailing Address - Country:US
Mailing Address - Phone:248-336-4000
Mailing Address - Fax:248-336-9137
Practice Address - Street 1:911 E 9 MILE RD
Practice Address - Street 2:
Practice Address - City:FERNDALE
Practice Address - State:MI
Practice Address - Zip Code:48220-1934
Practice Address - Country:US
Practice Address - Phone:248-336-4000
Practice Address - Fax:248-336-9137
Is Sole Proprietor?:No
Enumeration Date:2017-01-20
Last Update Date:2017-01-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI86045745133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered