Provider Demographics
NPI:1366554313
Name:HOOPER, TERESA ELIAS (PSYD,LTD)
Entity type:Individual
Prefix:
First Name:TERESA
Middle Name:ELIAS
Last Name:HOOPER
Suffix:
Gender:F
Credentials:PSYD,LTD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:730 AVIGNON DR STE 102
Mailing Address - Street 2:
Mailing Address - City:RIDGELAND
Mailing Address - State:MS
Mailing Address - Zip Code:39157-5164
Mailing Address - Country:US
Mailing Address - Phone:601-982-8531
Mailing Address - Fax:601-982-1115
Practice Address - Street 1:730 AVIGNON DR STE 102
Practice Address - Street 2:
Practice Address - City:RIDGELAND
Practice Address - State:MS
Practice Address - Zip Code:39157
Practice Address - Country:US
Practice Address - Phone:601-856-0582
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-31
Last Update Date:2018-07-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS33543103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS00120519Medicaid
MS680000106Medicare ID - Type Unspecified
S01524Medicare UPIN