Provider Demographics
NPI:1326407974
Name:TEAGUE, STEPHENIE
Entity type:Individual
Prefix:
First Name:STEPHENIE
Middle Name:
Last Name:TEAGUE
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:501 DEER TRL
Mailing Address - Street 2:
Mailing Address - City:CARBONDALE
Mailing Address - State:IL
Mailing Address - Zip Code:62901-5246
Mailing Address - Country:US
Mailing Address - Phone:916-690-0558
Mailing Address - Fax:
Practice Address - Street 1:700 MASSACHUSETTS AVE FL 3
Practice Address - Street 2:
Practice Address - City:CAMBRIDGE
Practice Address - State:MA
Practice Address - Zip Code:02139-3345
Practice Address - Country:US
Practice Address - Phone:888-500-2067
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-02-10
Last Update Date:2025-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL180015931101YP2500X
IL150.105200104100000X
IL180.015931101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No104100000XBehavioral Health & Social Service ProvidersSocial Worker