Provider Demographics
NPI:1740230465
Name:VANNATTA, TERESA LYNN (PHD HSPP)
Entity Type:Individual
Prefix:DR
First Name:TERESA
Middle Name:LYNN
Last Name:VANNATTA
Suffix:
Gender:F
Credentials:PHD HSPP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4607 N WHEELING AVE
Mailing Address - Street 2:
Mailing Address - City:MUNCIE
Mailing Address - State:IN
Mailing Address - Zip Code:47304
Mailing Address - Country:US
Mailing Address - Phone:765-288-1110
Mailing Address - Fax:765-288-4044
Practice Address - Street 1:4607 N WHEELING AVE
Practice Address - Street 2:
Practice Address - City:MUNCIE
Practice Address - State:IN
Practice Address - Zip Code:47304
Practice Address - Country:US
Practice Address - Phone:765-288-1110
Practice Address - Fax:765-288-4044
Is Sole Proprietor?:No
Enumeration Date:2006-05-11
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN20040646A103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
000000299448OtherANTHEM BCBS
9999998666OtherMAGELLAN
256942OtherVALUE OPTIONS
9999998666OtherMAGELLAN
R33445Medicare UPIN