Provider Demographics
NPI:1376152355
Name:SIMONCIC, TEAGUE E (LMSW)
Entity Type:Individual
Prefix:
First Name:TEAGUE
Middle Name:E
Last Name:SIMONCIC
Suffix:
Gender:F
Credentials:LMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:214 S MAIN ST STE 206
Mailing Address - Street 2:
Mailing Address - City:ANN ARBOR
Mailing Address - State:MI
Mailing Address - Zip Code:48104-2122
Mailing Address - Country:US
Mailing Address - Phone:734-224-3822
Mailing Address - Fax:
Practice Address - Street 1:214 S MAIN ST STE 206
Practice Address - Street 2:
Practice Address - City:ANN ARBOR
Practice Address - State:MI
Practice Address - Zip Code:48104-2122
Practice Address - Country:US
Practice Address - Phone:734-224-3822
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-07-27
Last Update Date:2021-04-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6801096976104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker