Provider Demographics
NPI:1164589248
Name:TEAGLE, TANITA M (LCSW)
Entity Type:Individual
Prefix:MRS
First Name:TANITA
Middle Name:M
Last Name:TEAGLE
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:60 ALLOWAY DR
Mailing Address - Street 2:
Mailing Address - City:VILLA RICA
Mailing Address - State:GA
Mailing Address - Zip Code:30180-3818
Mailing Address - Country:US
Mailing Address - Phone:404-210-5546
Mailing Address - Fax:
Practice Address - Street 1:60 ALLOWAY DR
Practice Address - Street 2:
Practice Address - City:VILLA RICA
Practice Address - State:GA
Practice Address - Zip Code:30180-3818
Practice Address - Country:US
Practice Address - Phone:404-210-5546
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-02
Last Update Date:2011-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GACSW0035121041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical