Provider Demographics
NPI:1306902747
Name:MCDOUGLE, TERI (CSAC, ICS)
Entity type:Individual
Prefix:
First Name:TERI
Middle Name:
Last Name:MCDOUGLE
Suffix:
Gender:F
Credentials:CSAC, ICS
Other - Prefix:
Other - First Name:TERI
Other - Middle Name:
Other - Last Name:NEW
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:4647 MORMON COULEE RD
Mailing Address - Street 2:
Mailing Address - City:LA CROSSE
Mailing Address - State:WI
Mailing Address - Zip Code:54601-8225
Mailing Address - Country:US
Mailing Address - Phone:608-519-3080
Mailing Address - Fax:608-519-3083
Practice Address - Street 1:4647 MORMON COULEE RD
Practice Address - Street 2:
Practice Address - City:LA CROSSE
Practice Address - State:WI
Practice Address - Zip Code:54601-8225
Practice Address - Country:US
Practice Address - Phone:608-519-3080
Practice Address - Fax:608-519-3083
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-29
Last Update Date:2012-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WY1540-132101YA0400X
WI12192-134101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)