Provider Demographics
NPI:1407368889
Name:BLACK, TERESA DAWN (LMFT-C)
Entity Type:Individual
Prefix:
First Name:TERESA
Middle Name:DAWN
Last Name:BLACK
Suffix:
Gender:F
Credentials:LMFT-C
Other - Prefix:
Other - First Name:TERESA
Other - Middle Name:DAWN
Other - Last Name:BEATY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:REGISTERED PSYCHOTHE
Mailing Address - Street 1:715 HORIZON DR STE 225
Mailing Address - Street 2:
Mailing Address - City:GRAND JUNCTION
Mailing Address - State:CO
Mailing Address - Zip Code:81506-8743
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:515 28 3/4 RD
Practice Address - Street 2:
Practice Address - City:GRAND JUNCTION
Practice Address - State:CO
Practice Address - Zip Code:81501-5016
Practice Address - Country:US
Practice Address - Phone:970-241-6023
Practice Address - Fax:970-242-8330
Is Sole Proprietor?:No
Enumeration Date:2017-10-25
Last Update Date:2023-06-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COMFTC.0014454101YM0800X, 106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health