Provider Demographics
NPI:1992007041
Name:BEARY-TAYLOR, THERESA (LCSW)
Entity Type:Individual
Prefix:
First Name:THERESA
Middle Name:
Last Name:BEARY-TAYLOR
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2238 1ST ST
Mailing Address - Street 2:
Mailing Address - City:SLIDELL
Mailing Address - State:LA
Mailing Address - Zip Code:70458-3606
Mailing Address - Country:US
Mailing Address - Phone:985-690-6622
Mailing Address - Fax:985-690-6662
Practice Address - Street 1:2238 1ST ST
Practice Address - Street 2:
Practice Address - City:SLIDELL
Practice Address - State:LA
Practice Address - Zip Code:70458-3606
Practice Address - Country:US
Practice Address - Phone:985-690-6622
Practice Address - Fax:985-690-6662
Is Sole Proprietor?:No
Enumeration Date:2010-11-23
Last Update Date:2010-11-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA45471041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA202977783OtherTAX ID #