Provider Demographics
NPI:1003905464
Name:TEBAY, BRENDA LEA (MA)
Entity Type:Individual
Prefix:MS
First Name:BRENDA
Middle Name:LEA
Last Name:TEBAY
Suffix:
Gender:F
Credentials:MA
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 373
Mailing Address - Street 2:
Mailing Address - City:HARRISVILLE
Mailing Address - State:WV
Mailing Address - Zip Code:26362-0373
Mailing Address - Country:US
Mailing Address - Phone:304-643-4005
Mailing Address - Fax:304-643-4007
Practice Address - Street 1:1200 STEPHENSON AVE STE 400
Practice Address - Street 2:
Practice Address - City:PARKERSBURG
Practice Address - State:WV
Practice Address - Zip Code:26101-4889
Practice Address - Country:US
Practice Address - Phone:304-699-0506
Practice Address - Fax:304-422-8850
Is Sole Proprietor?:No
Enumeration Date:2006-10-12
Last Update Date:2020-03-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WVWV 878103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV3810000161Medicaid