Provider Demographics
NPI:1558577965
Name:TEAGUE, GERALD VANCE (PHD)
Entity Type:Individual
Prefix:DR
First Name:GERALD
Middle Name:VANCE
Last Name:TEAGUE
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:851 LINDY LN
Mailing Address - Street 2:
Mailing Address - City:HUNTINGTOWN
Mailing Address - State:MD
Mailing Address - Zip Code:20639-9591
Mailing Address - Country:US
Mailing Address - Phone:410-257-2851
Mailing Address - Fax:
Practice Address - Street 1:851 LINDY LN
Practice Address - Street 2:
Practice Address - City:HUNTINGTOWN
Practice Address - State:MD
Practice Address - Zip Code:20639-9591
Practice Address - Country:US
Practice Address - Phone:410-257-2851
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-15
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDLCM021106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist