Provider Demographics
NPI:1356980239
Name:TEAGUE, MCKENNA TROI (LCSW)
Entity type:Individual
Prefix:
First Name:MCKENNA
Middle Name:TROI
Last Name:TEAGUE
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 1:4720 NE GLISAN ST APT 103
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97213-2967
Mailing Address - Country:US
Mailing Address - Phone:970-795-8874
Mailing Address - Fax:
Practice Address - Street 1:4224 NE HALSEY ST STE 335
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97213-1568
Practice Address - Country:US
Practice Address - Phone:970-795-8774
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-12-24
Last Update Date:2023-03-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
104100000X
COCSW.099279461041C0700X
ORL136311041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No104100000XBehavioral Health & Social Service ProvidersSocial Worker