Provider Demographics
NPI:1750821856
Name:TEAGUE, MICHAEL
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:
Last Name:TEAGUE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:816 KELLER PKWY
Mailing Address - Street 2:#200
Mailing Address - City:KELLER
Mailing Address - State:TX
Mailing Address - Zip Code:76248-2479
Mailing Address - Country:US
Mailing Address - Phone:817-200-7445
Mailing Address - Fax:
Practice Address - Street 1:816 KELLER PKWY
Practice Address - Street 2:#200
Practice Address - City:KELLER
Practice Address - State:TX
Practice Address - Zip Code:76248-2479
Practice Address - Country:US
Practice Address - Phone:817-200-7445
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-03-08
Last Update Date:2017-03-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1287568225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist