Provider Demographics
NPI:1124620307
Name:GORIS-TEAGUE, SANDRA (LPC)
Entity type:Individual
Prefix:
First Name:SANDRA
Middle Name:
Last Name:GORIS-TEAGUE
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1000 JEFFERSON ST.
Mailing Address - Street 2:STE. 2C
Mailing Address - City:LYNCHBURG
Mailing Address - State:VA
Mailing Address - Zip Code:24504
Mailing Address - Country:US
Mailing Address - Phone:617-453-9505
Mailing Address - Fax:
Practice Address - Street 1:3804 POPLAR HILL RD UNIT D
Practice Address - Street 2:
Practice Address - City:CHESAPEAKE
Practice Address - State:VA
Practice Address - Zip Code:23321-5532
Practice Address - Country:US
Practice Address - Phone:757-414-6427
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-11-12
Last Update Date:2020-11-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0701009054101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional