Provider Demographics
NPI:1164766416
Name:BEASON, THERESA A (LPC)
Entity Type:Individual
Prefix:
First Name:THERESA
Middle Name:A
Last Name:BEASON
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:
Other - First Name:THERESA
Other - Middle Name:A
Other - Last Name:PETTIGREW
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 14261
Mailing Address - Street 2:
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77221-4261
Mailing Address - Country:US
Mailing Address - Phone:281-685-3447
Mailing Address - Fax:713-741-4360
Practice Address - Street 1:5330 GRIGGS RD
Practice Address - Street 2:C-104
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77021-3700
Practice Address - Country:US
Practice Address - Phone:281-685-3447
Practice Address - Fax:713-741-4360
Is Sole Proprietor?:Yes
Enumeration Date:2012-11-26
Last Update Date:2012-11-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX15498101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX0280034-01Medicaid