Provider Demographics
NPI:1184911158
Name:ROBERTS, TERESA L (PMHNP-BC)
Entity type:Individual
Prefix:
First Name:TERESA
Middle Name:L
Last Name:ROBERTS
Suffix:
Gender:F
Credentials:PMHNP-BC
Other - Prefix:
Other - First Name:TERESA
Other - Middle Name:L
Other - Last Name:BUSH
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:909 E STATE BLVD
Mailing Address - Street 2:
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46805-3404
Mailing Address - Country:US
Mailing Address - Phone:260-481-2700
Mailing Address - Fax:260-481-2709
Practice Address - Street 1:909 E STATE BLVD
Practice Address - Street 2:
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46805
Practice Address - Country:US
Practice Address - Phone:260-481-2700
Practice Address - Fax:260-481-2709
Is Sole Proprietor?:No
Enumeration Date:2011-06-29
Last Update Date:2022-10-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN28195388A163WP0809X
IN71008269A363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No163WP0809XNursing Service ProvidersRegistered NursePsychiatric/Mental Health, Adult