Provider Demographics
NPI:1912449612
Name:BARNES, CYNTHIA TEDDER (MED,RPT)
Entity Type:Individual
Prefix:
First Name:CYNTHIA
Middle Name:TEDDER
Last Name:BARNES
Suffix:
Gender:F
Credentials:MED,RPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:285 SABINAL ST
Mailing Address - Street 2:
Mailing Address - City:BOLING
Mailing Address - State:TX
Mailing Address - Zip Code:77420-3410
Mailing Address - Country:US
Mailing Address - Phone:979-618-9198
Mailing Address - Fax:855-609-1957
Practice Address - Street 1:16628 HWY 36
Practice Address - Street 2:
Practice Address - City:NEEDVILLE
Practice Address - State:TX
Practice Address - Zip Code:77420
Practice Address - Country:US
Practice Address - Phone:979-618-9198
Practice Address - Fax:855-609-1957
Is Sole Proprietor?:Yes
Enumeration Date:2016-11-11
Last Update Date:2019-11-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX73473101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX366747901Medicaid