Basic Information
| Provider Information | |||||||||
| NPI: | 1336424621 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | EMERY | ||||||||
| FirstName: | TERESA | ||||||||
| MiddleName: | LEIGH | ||||||||
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| Credential: | MA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 621 W MADRONE ST | ||||||||
| Address2: | SUITE E | ||||||||
| City: | ROSEBURG | ||||||||
| State: | OR | ||||||||
| PostalCode: | 974703090 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5414403532 | ||||||||
| FaxNumber: | 5414403554 | ||||||||
| Practice Location | |||||||||
| Address1: | 272 MEDICAL LOOP | ||||||||
| Address2: | SUITE C | ||||||||
| City: | ROSEBURG | ||||||||
| State: | OR | ||||||||
| PostalCode: | 97471 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5414403532 | ||||||||
| FaxNumber: | 5414403554 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/18/2011 | ||||||||
| LastUpdateDate: | 01/03/2017 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YP2500X | OR | Y | Behavioral Health & Social Service Providers | Counselor | Professional |
ID Information
| ID | Type | State | Issuer | Description | 500662810 | 05 | OR | MEDICAID |