Provider Demographics
NPI:1679051254
Name:ELDER, THERESA A
Entity type:Individual
Prefix:
First Name:THERESA
Middle Name:A
Last Name:ELDER
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 1:2460 PEBBLE BEACH DR
Mailing Address - Street 2:
Mailing Address - City:OAKLAND
Mailing Address - State:MI
Mailing Address - Zip Code:48363-2445
Mailing Address - Country:US
Mailing Address - Phone:248-840-7753
Mailing Address - Fax:
Practice Address - Street 1:800 S WASHINGTON AVE
Practice Address - Street 2:
Practice Address - City:SAGINAW
Practice Address - State:MI
Practice Address - Zip Code:48601-2551
Practice Address - Country:US
Practice Address - Phone:248-840-7753
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-08-05
Last Update Date:2018-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1202442312Medicaid