Provider Demographics
NPI:1184726036
Name:VON WOGLOM, TERESA C (LCSW, LPC)
Entity type:Individual
Prefix:MS
First Name:TERESA
Middle Name:C
Last Name:VON WOGLOM
Suffix:
Gender:F
Credentials:LCSW, LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:455 SCHOOL ST
Mailing Address - Street 2:SUITE 14
Mailing Address - City:TOMBALL
Mailing Address - State:TX
Mailing Address - Zip Code:77375-4593
Mailing Address - Country:US
Mailing Address - Phone:281-351-6561
Mailing Address - Fax:281-516-7159
Practice Address - Street 1:455 SCHOOL ST
Practice Address - Street 2:SUITE 14
Practice Address - City:TOMBALL
Practice Address - State:TX
Practice Address - Zip Code:77375-4593
Practice Address - Country:US
Practice Address - Phone:281-351-6561
Practice Address - Fax:281-516-7159
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-02
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX022671041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX226924OtherVALUE OPTIONS
TX0099JNOtherBCBS
TX00963HMedicare ID - Type Unspecified