Provider Demographics
NPI:1417412578
Name:FLEAGLE, TERESA (LSW)
Entity type:Individual
Prefix:
First Name:TERESA
Middle Name:
Last Name:FLEAGLE
Suffix:
Gender:F
Credentials:LSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:33 W 1ST ST STE 100
Mailing Address - Street 2:
Mailing Address - City:DAYTON
Mailing Address - State:OH
Mailing Address - Zip Code:45402-1243
Mailing Address - Country:US
Mailing Address - Phone:937-293-1945
Mailing Address - Fax:937-293-8150
Practice Address - Street 1:33 W 1ST ST STE 100
Practice Address - Street 2:
Practice Address - City:DAYTON
Practice Address - State:OH
Practice Address - Zip Code:45402-1243
Practice Address - Country:US
Practice Address - Phone:937-293-1945
Practice Address - Fax:937-293-8150
Is Sole Proprietor?:Yes
Enumeration Date:2019-02-04
Last Update Date:2019-02-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHS.0029555104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker