Provider Demographics
NPI:1427574557
Name:MACON, TERESA (CDCA)
Entity Type:Individual
Prefix:
First Name:TERESA
Middle Name:
Last Name:MACON
Suffix:
Gender:F
Credentials:CDCA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2828 VERNON PL
Mailing Address - Street 2:
Mailing Address - City:CINCINNATI
Mailing Address - State:OH
Mailing Address - Zip Code:45219-2414
Mailing Address - Country:US
Mailing Address - Phone:513-281-7880
Mailing Address - Fax:513-281-7884
Practice Address - Street 1:2828 VERNON PL
Practice Address - Street 2:
Practice Address - City:CINCINNATI
Practice Address - State:OH
Practice Address - Zip Code:45219-2414
Practice Address - Country:US
Practice Address - Phone:513-281-7880
Practice Address - Fax:513-281-7884
Is Sole Proprietor?:Yes
Enumeration Date:2017-08-21
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH150415101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)