Provider Demographics
NPI:1063407088
Name:MADSEN, TERESA ANN (CCSC II BS ALLIED)
Entity type:Individual
Prefix:MRS
First Name:TERESA
Middle Name:ANN
Last Name:MADSEN
Suffix:
Gender:F
Credentials:CCSC II BS ALLIED
Other - Prefix:MRS
Other - First Name:TERESA
Other - Middle Name:ANN
Other - Last Name:JOHNSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 1030
Mailing Address - Street 2:
Mailing Address - City:WATERTOWN
Mailing Address - State:SD
Mailing Address - Zip Code:57201-6030
Mailing Address - Country:US
Mailing Address - Phone:605-886-0123
Mailing Address - Fax:605-886-5447
Practice Address - Street 1:123 19TH ST NE
Practice Address - Street 2:
Practice Address - City:WATERTOWN
Practice Address - State:SD
Practice Address - Zip Code:57201-2823
Practice Address - Country:US
Practice Address - Phone:605-886-0123
Practice Address - Fax:605-886-5447
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-09-15
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SD9607928101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor