Provider Demographics
NPI:1366864100
Name:TEAL, MARA (LCMHC)
Entity Type:Individual
Prefix:
First Name:MARA
Middle Name:
Last Name:TEAL
Suffix:
Gender:F
Credentials:LCMHC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6135 PARK SOUTH DR STE 130
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28210-3270
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:6135 PARK SOUTH DR STE 130
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28210-3270
Practice Address - Country:US
Practice Address - Phone:704-237-0133
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-01-14
Last Update Date:2022-01-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC10366101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health