Provider Demographics
NPI:1740606656
Name:TELLER, LAUREL (MA, CCC-SLP)
Entity Type:Individual
Prefix:
First Name:LAUREL
Middle Name:
Last Name:TELLER
Suffix:
Gender:F
Credentials:MA, CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9092 MARAL TRL
Mailing Address - Street 2:
Mailing Address - City:CENTERVILLE
Mailing Address - State:OH
Mailing Address - Zip Code:45458-3629
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:407 AMBROSE CT
Practice Address - Street 2:
Practice Address - City:DAYTON
Practice Address - State:OH
Practice Address - Zip Code:45410-1556
Practice Address - Country:US
Practice Address - Phone:937-542-5640
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-03-16
Last Update Date:2014-03-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHSP.10170235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist