Provider Demographics
NPI:1073235677
Name:TEAL, ALEXANDRA
Entity Type:Individual
Prefix:
First Name:ALEXANDRA
Middle Name:
Last Name:TEAL
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 1:110 W LOCUST ST
Mailing Address - Street 2:
Mailing Address - City:GALATIA
Mailing Address - State:IL
Mailing Address - Zip Code:62935-1000
Mailing Address - Country:US
Mailing Address - Phone:618-499-3443
Mailing Address - Fax:
Practice Address - Street 1:315 E CHURCH ST
Practice Address - Street 2:
Practice Address - City:HARRISBURG
Practice Address - State:IL
Practice Address - Zip Code:62946-1708
Practice Address - Country:US
Practice Address - Phone:618-253-7637
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-09-12
Last Update Date:2022-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL146.016185235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist