Provider Demographics
NPI:1184372914
Name:MILICIA A. TEDDER
Entity type:Organization
Organization Name:MILICIA A. TEDDER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:LPA
Authorized Official - Prefix:
Authorized Official - First Name:MILICIA
Authorized Official - Middle Name:
Authorized Official - Last Name:TEDDER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:336-569-0420
Mailing Address - Street 1:4093 DUNKIRK DR
Mailing Address - Street 2:
Mailing Address - City:BURLINGTON
Mailing Address - State:NC
Mailing Address - Zip Code:27215-0106
Mailing Address - Country:US
Mailing Address - Phone:919-697-1674
Mailing Address - Fax:
Practice Address - Street 1:115 E HARDEN ST STE 103
Practice Address - Street 2:
Practice Address - City:GRAHAM
Practice Address - State:NC
Practice Address - Zip Code:27253-3001
Practice Address - Country:US
Practice Address - Phone:336-569-0420
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-03-10
Last Update Date:2022-03-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)