Provider Demographics
NPI:1619914132
Name:MCDONALD, TERESA D (LSCSW)
Entity Type:Individual
Prefix:MRS
First Name:TERESA
Middle Name:D
Last Name:MCDONALD
Suffix:
Gender:F
Credentials:LSCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6525 E MAINSGATE RD
Mailing Address - Street 2:
Mailing Address - City:WICHITA
Mailing Address - State:KS
Mailing Address - Zip Code:67226-1062
Mailing Address - Country:US
Mailing Address - Phone:316-461-7923
Mailing Address - Fax:316-260-7045
Practice Address - Street 1:6525 E MAINSGATE RD
Practice Address - Street 2:
Practice Address - City:WICHITA
Practice Address - State:KS
Practice Address - Zip Code:67226-1062
Practice Address - Country:US
Practice Address - Phone:316-461-7923
Practice Address - Fax:316-260-7045
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-01
Last Update Date:2016-10-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS35981041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS829998OtherBLUE CROSS BLUE SHIELD
KS13550OtherPREFERRED HEALTH SYSTEMS
KS829998Medicare ID - Type Unspecified
KSQ59766Medicare UPIN