Provider Demographics
NPI:1235193962
Name:TEALL, BRUCE (LCSW)
Entity Type:Individual
Prefix:MR
First Name:BRUCE
Middle Name:
Last Name:TEALL
Suffix:
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11 SENECA AVE
Mailing Address - Street 2:
Mailing Address - City:GENESEO
Mailing Address - State:NY
Mailing Address - Zip Code:14454-9508
Mailing Address - Country:US
Mailing Address - Phone:585-314-4618
Mailing Address - Fax:
Practice Address - Street 1:401 PENFIELD DR.
Practice Address - Street 2:BLDG #3
Practice Address - City:PENFIELD
Practice Address - State:NY
Practice Address - Zip Code:14526
Practice Address - Country:US
Practice Address - Phone:585-314-4618
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-04-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYR054197-11041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical