Provider Demographics
NPI:1952470635
Name:COVINGTON, THERESA M (PHD)
Entity Type:Individual
Prefix:
First Name:THERESA
Middle Name:M
Last Name:COVINGTON
Suffix:
Gender:F
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:PO BOX 58
Mailing Address - Street 2:
Mailing Address - City:BALDWINSVILLE
Mailing Address - State:NY
Mailing Address - Zip Code:13027-0058
Mailing Address - Country:US
Mailing Address - Phone:315-935-3037
Mailing Address - Fax:315-295-2614
Practice Address - Street 1:2605 BREWERTON RD
Practice Address - Street 2:
Practice Address - City:MATTYDALE
Practice Address - State:NY
Practice Address - Zip Code:13211-1147
Practice Address - Country:US
Practice Address - Phone:315-935-3037
Practice Address - Fax:315-295-2614
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-07
Last Update Date:2014-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CTCT002407103G00000X
NY012316103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No103G00000XBehavioral Health & Social Service ProvidersClinical Neuropsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CTCT002407OtherLICENSE
CTCT002407OtherLICENSE
CT680001661Medicare ID - Type UnspecifiedMEDICARE