Provider Demographics
NPI:1821454901
Name:TRAVERSO, TERESA (LPC)
Entity Type:Individual
Prefix:MS
First Name:TERESA
Middle Name:
Last Name:TRAVERSO
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:23332 ORCHARD LAKE RD STE C
Mailing Address - Street 2:
Mailing Address - City:FARMINGTON HILLS
Mailing Address - State:MI
Mailing Address - Zip Code:48336-3280
Mailing Address - Country:US
Mailing Address - Phone:313-400-1705
Mailing Address - Fax:
Practice Address - Street 1:23332 ORCHARD LAKE RD STE C
Practice Address - Street 2:
Practice Address - City:FARMINGTON HILLS
Practice Address - State:MI
Practice Address - Zip Code:48336-3280
Practice Address - Country:US
Practice Address - Phone:313-400-1705
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-01-06
Last Update Date:2020-06-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6401007671101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1821454901Medicaid