Provider Demographics
NPI:1821098922
Name:TEAGUE, JAMES BRADLEY (PHD)
Entity Type:Individual
Prefix:DR
First Name:JAMES
Middle Name:BRADLEY
Last Name:TEAGUE
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6470 N SHADELAND AVE
Mailing Address - Street 2:SUITE C
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46220-4390
Mailing Address - Country:US
Mailing Address - Phone:317-849-9509
Mailing Address - Fax:317-841-1157
Practice Address - Street 1:6470 N SHADELAND AVE
Practice Address - Street 2:SUITE C
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46220-4390
Practice Address - Country:US
Practice Address - Phone:317-849-9509
Practice Address - Fax:317-841-1157
Is Sole Proprietor?:Yes
Enumeration Date:2005-07-29
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN20040735103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN245610Medicare ID - Type UnspecifiedMEDICARE