Provider Demographics
NPI:1114931664
Name:HAGWOOD, TERESA WOODWARD (LCSW)
Entity Type:Individual
Prefix:MRS
First Name:TERESA
Middle Name:WOODWARD
Last Name:HAGWOOD
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:TERESA
Other - Middle Name:KAY
Other - Last Name:WOODWARD
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LCSW
Mailing Address - Street 1:400 VETERANS AVE
Mailing Address - Street 2:PRIMARY CARE MENTAL HEALTH
Mailing Address - City:BILOXI
Mailing Address - State:MS
Mailing Address - Zip Code:39531-2410
Mailing Address - Country:US
Mailing Address - Phone:228-523-4797
Mailing Address - Fax:
Practice Address - Street 1:400 VETERANS AVE
Practice Address - Street 2:PRIMARY CARE MENTAL HEALTH
Practice Address - City:BILOXI
Practice Address - State:MS
Practice Address - Zip Code:39531-2410
Practice Address - Country:US
Practice Address - Phone:228-523-4797
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-28
Last Update Date:2013-03-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSC31311041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS00125717Medicaid
MS00125717Medicaid