Provider Demographics
NPI:1679039598
Name:GINGRAS, TERESA
Entity Type:Individual
Prefix:
First Name:TERESA
Middle Name:
Last Name:GINGRAS
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 1:2412 COMPTROLLERS CT
Mailing Address - Street 2:
Mailing Address - City:PRINCE FREDERICK
Mailing Address - State:MD
Mailing Address - Zip Code:20678-4340
Mailing Address - Country:US
Mailing Address - Phone:913-522-7159
Mailing Address - Fax:
Practice Address - Street 1:2412 COMPTROLLERS CT
Practice Address - Street 2:
Practice Address - City:PRINCE FREDERICK
Practice Address - State:MD
Practice Address - Zip Code:20678-4340
Practice Address - Country:US
Practice Address - Phone:443-295-3015
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-02-15
Last Update Date:2023-01-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDRBT-16-18837106S00000X
1-21-48616103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
No106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD483106300Medicaid