Provider Demographics
NPI:1962444356
Name:LINEBACK, TERESA M (MED)
Entity Type:Individual
Prefix:MRS
First Name:TERESA
Middle Name:M
Last Name:LINEBACK
Suffix:
Gender:F
Credentials:MED
Other - Prefix:MRS
Other - First Name:TESS
Other - Middle Name:
Other - Last Name:LINEBACK
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MED
Mailing Address - Street 1:310 KING GEORGE LOOP
Mailing Address - Street 2:
Mailing Address - City:CARY
Mailing Address - State:NC
Mailing Address - Zip Code:27511-6322
Mailing Address - Country:US
Mailing Address - Phone:919-467-3868
Mailing Address - Fax:
Practice Address - Street 1:106 RIDGE VIEW DR
Practice Address - Street 2:
Practice Address - City:CARY
Practice Address - State:NC
Practice Address - Zip Code:27511-6647
Practice Address - Country:US
Practice Address - Phone:919-467-9995
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-06-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC608101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC608OtherLPC
NY26OtherLEAP