Provider Demographics
NPI:1104411552
Name:TEETER, ALICIA M (MS, PPC)
Entity type:Individual
Prefix:
First Name:ALICIA
Middle Name:M
Last Name:TEETER
Suffix:
Gender:F
Credentials:MS, PPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2404 S EMERSON AVE APT B
Mailing Address - Street 2:
Mailing Address - City:GILLETTE
Mailing Address - State:WY
Mailing Address - Zip Code:82718-3811
Mailing Address - Country:US
Mailing Address - Phone:208-201-5237
Mailing Address - Fax:
Practice Address - Street 1:201 W LAKEWAY RD STE 400
Practice Address - Street 2:
Practice Address - City:GILLETTE
Practice Address - State:WY
Practice Address - Zip Code:82718-6307
Practice Address - Country:US
Practice Address - Phone:307-686-0808
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-03-08
Last Update Date:2021-03-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WYPPC-1211101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor