Provider Demographics
NPI:1043692437
Name:NORTHLAKE MEDICAL PSYCHOLOGY AND COUNSELING
Entity Type:Organization
Organization Name:NORTHLAKE MEDICAL PSYCHOLOGY AND COUNSELING
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEDICAL PSYCHOLOGIST
Authorized Official - Prefix:
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:A
Authorized Official - Last Name:TEAL
Authorized Official - Suffix:
Authorized Official - Credentials:PHD, MP
Authorized Official - Phone:601-946-1844
Mailing Address - Street 1:215 SAINT ANN DR STE 2
Mailing Address - Street 2:
Mailing Address - City:MANDEVILLE
Mailing Address - State:LA
Mailing Address - Zip Code:70471-3394
Mailing Address - Country:US
Mailing Address - Phone:601-946-1844
Mailing Address - Fax:
Practice Address - Street 1:215 SAINT ANN DR STE 2
Practice Address - Street 2:
Practice Address - City:MANDEVILLE
Practice Address - State:LA
Practice Address - Zip Code:70471-3394
Practice Address - Country:US
Practice Address - Phone:601-946-1844
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-06-23
Last Update Date:2015-07-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LAMP.000036261QM0801X
LALPC #3492261QM0801X
LAMP.0020261QM0801X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)