Provider Demographics
NPI:1689799348
Name:PERSSON, TERESA M (MS LPC)
Entity Type:Individual
Prefix:
First Name:TERESA
Middle Name:M
Last Name:PERSSON
Suffix:
Gender:F
Credentials:MS LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1590 SE N ST STE D
Mailing Address - Street 2:
Mailing Address - City:GRANTS PASS
Mailing Address - State:OR
Mailing Address - Zip Code:97526-3905
Mailing Address - Country:US
Mailing Address - Phone:541-621-2686
Mailing Address - Fax:
Practice Address - Street 1:1590 SE N ST STE D
Practice Address - Street 2:
Practice Address - City:GRANTS PASS
Practice Address - State:OR
Practice Address - Zip Code:97526-3905
Practice Address - Country:US
Practice Address - Phone:541-621-2686
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-20
Last Update Date:2013-04-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YM0800X
ORC2034101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health