Provider Demographics
NPI:1619176773
Name:TEAGUE, MELISSA LONDON
Entity Type:Individual
Prefix:
First Name:MELISSA
Middle Name:LONDON
Last Name:TEAGUE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:420 N CENTER ST
Mailing Address - Street 2:
Mailing Address - City:HICKORY
Mailing Address - State:NC
Mailing Address - Zip Code:28601-5033
Mailing Address - Country:US
Mailing Address - Phone:828-315-5092
Mailing Address - Fax:
Practice Address - Street 1:420 N CENTER ST
Practice Address - Street 2:
Practice Address - City:HICKORY
Practice Address - State:NC
Practice Address - Zip Code:28601-5033
Practice Address - Country:US
Practice Address - Phone:828-315-5092
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-07-17
Last Update Date:2012-07-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCC0057451041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC148FWOtherBCBSNC
NC6106724Medicaid
NC148FWOtherBCBSNC