Provider Demographics
NPI:1386212652
Name:RUSSEAU, TEAL MARIE
Entity Type:Individual
Prefix:
First Name:TEAL
Middle Name:MARIE
Last Name:RUSSEAU
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:101 SWEETEN GRASS HILL
Mailing Address - Street 2:APT 205
Mailing Address - City:ARDEN
Mailing Address - State:NC
Mailing Address - Zip Code:28704
Mailing Address - Country:US
Mailing Address - Phone:630-991-6816
Mailing Address - Fax:
Practice Address - Street 1:9 W SUMMIT AVE
Practice Address - Street 2:
Practice Address - City:ASHEVILLE
Practice Address - State:NC
Practice Address - Zip Code:28803-0047
Practice Address - Country:US
Practice Address - Phone:828-670-8056
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-06-14
Last Update Date:2021-06-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCA16565101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health