Provider Demographics
NPI:1467565549
Name:TEATER, JULIE DAWN (PSYD)
Entity Type:Individual
Prefix:DR
First Name:JULIE
Middle Name:DAWN
Last Name:TEATER
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1907 PASS RD
Mailing Address - Street 2:SUITE G
Mailing Address - City:BILOXI
Mailing Address - State:MS
Mailing Address - Zip Code:39531-4101
Mailing Address - Country:US
Mailing Address - Phone:228-594-9010
Mailing Address - Fax:228-594-9012
Practice Address - Street 1:1907 PASS RD
Practice Address - Street 2:SUITE G
Practice Address - City:BILOXI
Practice Address - State:MS
Practice Address - Zip Code:39531-4101
Practice Address - Country:US
Practice Address - Phone:228-594-9010
Practice Address - Fax:228-594-9012
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-16
Last Update Date:2010-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS39-002103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS562344223OtherTAX INDENTIFICATION #
MS680000250Medicare ID - Type Unspecified
MS562344223OtherTAX INDENTIFICATION #