Provider Demographics
NPI:1114447166
Name:TEAL, LAURIE B (PMHNP)
Entity Type:Individual
Prefix:
First Name:LAURIE
Middle Name:B
Last Name:TEAL
Suffix:
Gender:F
Credentials:PMHNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:725 JUNIPER SWAMP RD
Mailing Address - Street 2:
Mailing Address - City:SHUSHAN
Mailing Address - State:NY
Mailing Address - Zip Code:12873-2910
Mailing Address - Country:US
Mailing Address - Phone:518-812-6842
Mailing Address - Fax:518-338-0174
Practice Address - Street 1:725 JUNIPER SWAMP RD
Practice Address - Street 2:
Practice Address - City:SHUSHAN
Practice Address - State:NY
Practice Address - Zip Code:12873-2910
Practice Address - Country:US
Practice Address - Phone:518-812-6842
Practice Address - Fax:518-338-0174
Is Sole Proprietor?:Yes
Enumeration Date:2017-06-21
Last Update Date:2022-03-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VT101-0131597363LP0808X
NYF4021521364SP0809X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental HealthGroup - Multi-Specialty
No364SP0809XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse SpecialistPsychiatric/Mental Health, AdultGroup - Multi-Specialty