Provider Demographics
NPI:1457890097
Name:DEMENT, TERESA S (LPCC, LICDC)
Entity Type:Individual
Prefix:
First Name:TERESA
Middle Name:S
Last Name:DEMENT
Suffix:
Gender:F
Credentials:LPCC, LICDC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1220 W HUNTER ST
Mailing Address - Street 2:
Mailing Address - City:LOGAN
Mailing Address - State:OH
Mailing Address - Zip Code:43138-1012
Mailing Address - Country:US
Mailing Address - Phone:740-205-2999
Mailing Address - Fax:740-216-4501
Practice Address - Street 1:1220 W HUNTER ST
Practice Address - Street 2:
Practice Address - City:LOGAN
Practice Address - State:OH
Practice Address - Zip Code:43138-1012
Practice Address - Country:US
Practice Address - Phone:740-205-2999
Practice Address - Fax:740-216-4501
Is Sole Proprietor?:Yes
Enumeration Date:2017-02-15
Last Update Date:2019-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHLICDC.161833101YA0400X
OHE.1901231101YM0800X, 101YM0800X
OHC1500161101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)