Provider Demographics
NPI:1215914742
Name:RAY, TERESA CHILDRES (MA, NCC, LPC)
Entity type:Individual
Prefix:
First Name:TERESA
Middle Name:CHILDRES
Last Name:RAY
Suffix:
Gender:F
Credentials:MA, NCC, LPC
Other - Prefix:
Other - First Name:TERRI
Other - Middle Name:C
Other - Last Name:RAY
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MA, NCC, LPC
Mailing Address - Street 1:PO BOX 3984
Mailing Address - Street 2:
Mailing Address - City:GASTONIA
Mailing Address - State:NC
Mailing Address - Zip Code:28054-0020
Mailing Address - Country:US
Mailing Address - Phone:704-861-8405
Mailing Address - Fax:704-865-0590
Practice Address - Street 1:258 E GARRISON BLVD
Practice Address - Street 2:
Practice Address - City:GASTONIA
Practice Address - State:NC
Practice Address - Zip Code:28054-0460
Practice Address - Country:US
Practice Address - Phone:704-861-8405
Practice Address - Fax:704-865-0590
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-12-27
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC2295101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
NCB4131OtherMEDCOST.DOC ID #
NC6005064Medicaid
NC0258GOtherBCBS GROUP PIN
NC1039EOtherBCBS PROVIDER PIN
NC6102251Medicaid
NC7433388OtherAETNAGROUPBEHPIN
NC7361114OtherAETNA BEH.HEALTH PIN