Provider Demographics
NPI:1548789993
Name:WALLOP, TEONNA L (LCPC)
Entity Type:Individual
Prefix:
First Name:TEONNA
Middle Name:L
Last Name:WALLOP
Suffix:
Gender:F
Credentials:LCPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1711 BRIGHTWELL CT
Mailing Address - Street 2:
Mailing Address - City:WALDORF
Mailing Address - State:MD
Mailing Address - Zip Code:20602-1634
Mailing Address - Country:US
Mailing Address - Phone:202-580-9029
Mailing Address - Fax:301-850-1121
Practice Address - Street 1:1711 BRIGHTWELL CT
Practice Address - Street 2:
Practice Address - City:WALDORF
Practice Address - State:MD
Practice Address - Zip Code:20602-1634
Practice Address - Country:US
Practice Address - Phone:301-850-1121
Practice Address - Fax:301-850-1121
Is Sole Proprietor?:Yes
Enumeration Date:2017-09-18
Last Update Date:2017-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDLC4121101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
MDD962945Medicaid