Provider Demographics
NPI:1275539223
Name:BSULLAK, TERESA ELAINE (LCSW)
Entity Type:Individual
Prefix:
First Name:TERESA
Middle Name:ELAINE
Last Name:BSULLAK
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 1:241 GREENHOUSE RD
Mailing Address - Street 2:ATTN STEPHANIE BLACK
Mailing Address - City:LEXINGTON
Mailing Address - State:VA
Mailing Address - Zip Code:24450-3717
Mailing Address - Country:US
Mailing Address - Phone:540-463-3141
Mailing Address - Fax:540-464-4051
Practice Address - Street 1:241 GREENHOUSE RD
Practice Address - Street 2:ATTN STEPHANIE BLACK
Practice Address - City:LEXINGTON
Practice Address - State:VA
Practice Address - Zip Code:24450-3717
Practice Address - Country:US
Practice Address - Phone:540-463-3141
Practice Address - Fax:540-464-4051
Is Sole Proprietor?:No
Enumeration Date:2005-06-23
Last Update Date:2007-07-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA09040051471041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA800002925Medicare ID - Type Unspecified
P51641Medicare UPIN