Provider Demographics
NPI:1225048671
Name:TEALL, PETER THOMAS (LCSW-R, CASAC)
Entity Type:Individual
Prefix:MR
First Name:PETER
Middle Name:THOMAS
Last Name:TEALL
Suffix:
Gender:M
Credentials:LCSW-R, CASAC
Other - Prefix:MR
Other - First Name:PETER
Other - Middle Name:THOMAS
Other - Last Name:TEALL
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:LCSW-R, CASAC
Mailing Address - Street 1:496 WHITE SPRUCE BLVD
Mailing Address - Street 2:
Mailing Address - City:ROCHESTER
Mailing Address - State:NY
Mailing Address - Zip Code:14623-1608
Mailing Address - Country:US
Mailing Address - Phone:585-305-8759
Mailing Address - Fax:
Practice Address - Street 1:496 WHITE SPRUCE BLVD
Practice Address - Street 2:
Practice Address - City:ROCHESTER
Practice Address - State:NY
Practice Address - Zip Code:14623-1608
Practice Address - Country:US
Practice Address - Phone:585-305-8759
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-08
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY11606101YA0400X
NY071006-1101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Not Answered101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health