Provider Demographics
NPI:1891705802
Name:TEAGUE-SMITH, MALVA (MED)
Entity Type:Individual
Prefix:
First Name:MALVA
Middle Name:
Last Name:TEAGUE-SMITH
Suffix:
Gender:F
Credentials:MED
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5215 79TH ST
Mailing Address - Street 2:
Mailing Address - City:LUBBOCK
Mailing Address - State:TX
Mailing Address - Zip Code:79424-2832
Mailing Address - Country:US
Mailing Address - Phone:806-792-4713
Mailing Address - Fax:806-793-0231
Practice Address - Street 1:5215 79TH ST
Practice Address - Street 2:
Practice Address - City:LUBBOCK
Practice Address - State:TX
Practice Address - Zip Code:79424-2832
Practice Address - Country:US
Practice Address - Phone:806-792-4713
Practice Address - Fax:806-793-0231
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-09
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX9525101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX00079BOtherBLUE CROSS BLUE SHIELD
TXCOMPCAREOtherTEAGU-0006