Provider Demographics
NPI:1124636824
Name:BAILIFF, AUSTYN TEAL (LPC)
Entity type:Individual
Prefix:
First Name:AUSTYN
Middle Name:TEAL
Last Name:BAILIFF
Suffix:
Gender:M
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1058 ASHER WAY STE 400
Mailing Address - Street 2:
Mailing Address - City:TYLER
Mailing Address - State:TX
Mailing Address - Zip Code:75703-6076
Mailing Address - Country:US
Mailing Address - Phone:903-952-3757
Mailing Address - Fax:
Practice Address - Street 1:1058 ASHER WAY STE 400
Practice Address - Street 2:
Practice Address - City:TYLER
Practice Address - State:TX
Practice Address - Zip Code:75703-6076
Practice Address - Country:US
Practice Address - Phone:903-952-3757
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-07-19
Last Update Date:2020-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX78113101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional