Provider Demographics
NPI:1649465105
Name:VALENZUELA, THERESA JANE (LAC)
Entity type:Individual
Prefix:MS
First Name:THERESA
Middle Name:JANE
Last Name:VALENZUELA
Suffix:
Gender:F
Credentials:LAC
Other - Prefix:MISS
Other - First Name:THERESA
Other - Middle Name:JANE
Other - Last Name:GRYBOSKY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LAC
Mailing Address - Street 1:445 W BELL ST
Mailing Address - Street 2:
Mailing Address - City:SEQUIM
Mailing Address - State:WA
Mailing Address - Zip Code:98382-3758
Mailing Address - Country:US
Mailing Address - Phone:360-477-4781
Mailing Address - Fax:360-582-0999
Practice Address - Street 1:445 W BELL ST
Practice Address - Street 2:
Practice Address - City:SEQUIM
Practice Address - State:WA
Practice Address - Zip Code:98382-3758
Practice Address - Country:US
Practice Address - Phone:360-477-4781
Practice Address - Fax:360-582-0999
Is Sole Proprietor?:No
Enumeration Date:2007-09-07
Last Update Date:2007-09-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAAC00002476171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist