Provider Demographics
NPI:1558666867
Name:TEACHOUT, MARY (MPA, CPC, NCC)
Entity Type:Individual
Prefix:MRS
First Name:MARY
Middle Name:
Last Name:TEACHOUT
Suffix:
Gender:F
Credentials:MPA, CPC, NCC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1107 US HIGHWAY 395 N
Mailing Address - Street 2:
Mailing Address - City:GARDNERVILLE
Mailing Address - State:NV
Mailing Address - Zip Code:89410-5304
Mailing Address - Country:US
Mailing Address - Phone:248-390-4264
Mailing Address - Fax:
Practice Address - Street 1:1107 US HIGHWAY 395 N
Practice Address - Street 2:
Practice Address - City:GARDNERVILLE
Practice Address - State:NV
Practice Address - Zip Code:89410-5304
Practice Address - Country:US
Practice Address - Phone:248-390-4264
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-01-18
Last Update Date:2019-05-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6401010522101YP2500X
AK107328101YP2500X
MN889101YP2500X
NE2106101YP2500X
NVCP1149-R101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
AK1020986Medicaid
MI12183880OtherCAQH