Provider Demographics
NPI:1295208957
Name:EIDEM, TERRI (LCSW)
Entity Type:Individual
Prefix:
First Name:TERRI
Middle Name:
Last Name:EIDEM
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 1:124 RIVER LAKES LN
Mailing Address - Street 2:
Mailing Address - City:MARTINDALE
Mailing Address - State:TX
Mailing Address - Zip Code:78655-3907
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2020 FM 967
Practice Address - Street 2:
Practice Address - City:BUDA
Practice Address - State:TX
Practice Address - Zip Code:78610-2877
Practice Address - Country:US
Practice Address - Phone:512-523-8777
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-01-05
Last Update Date:2019-01-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX603461041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX24339407OtherSTATE OF TEXAS DRIVER LICENSE
TX60346OtherTEXAS STATE BOARD OF SOCIAL WORK EXAMINERS