Provider Demographics
NPI:1891411161
Name:WALTZ, TEEGAN NICOLE
Entity Type:Individual
Prefix:
First Name:TEEGAN
Middle Name:NICOLE
Last Name:WALTZ
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 1:1401 JOHNSON RD APT 53
Mailing Address - Street 2:
Mailing Address - City:CENTRALIA
Mailing Address - State:WA
Mailing Address - Zip Code:98531-4574
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3510 STEELHAMMER DR
Practice Address - Street 2:
Practice Address - City:CENTRALIA
Practice Address - State:WA
Practice Address - Zip Code:98531-4551
Practice Address - Country:US
Practice Address - Phone:360-623-8020
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-10-18
Last Update Date:2022-10-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA363A00000X
101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant