Provider Demographics
NPI:1255712139
Name:TERHUNE, TEDDY
Entity type:Individual
Prefix:
First Name:TEDDY
Middle Name:
Last Name:TERHUNE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:TEDDY
Other - Middle Name:
Other - Last Name:TERHUNE
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:JD, MA
Mailing Address - Street 1:5304A WOODROW AVE
Mailing Address - Street 2:
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78756-2107
Mailing Address - Country:US
Mailing Address - Phone:512-586-8118
Mailing Address - Fax:512-672-6166
Practice Address - Street 1:5304A WOODROW AVE
Practice Address - Street 2:
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78756-2107
Practice Address - Country:US
Practice Address - Phone:512-586-8118
Practice Address - Fax:512-672-6166
Is Sole Proprietor?:Yes
Enumeration Date:2015-06-16
Last Update Date:2018-09-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX69615101YP2500X, 101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
0004FROtherBLUECROSS BLUESHIELD OF TEXAS