Provider Demographics
NPI:1831677319
Name:MARSHALL-BLAND, TERESA LYNN
Entity Type:Individual
Prefix:
First Name:TERESA
Middle Name:LYNN
Last Name:MARSHALL-BLAND
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:214 BRECKENRIDGE LN
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40207-3868
Mailing Address - Country:US
Mailing Address - Phone:812-987-2043
Mailing Address - Fax:502-709-4264
Practice Address - Street 1:1218 W OAK ST
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40210-1533
Practice Address - Country:US
Practice Address - Phone:502-636-1572
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-08-06
Last Update Date:2018-08-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY103337101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional