Provider Demographics
NPI:1588706972
Name:TEAGUE, TIMOTHY J (PHD)
Entity type:Individual
Prefix:DR
First Name:TIMOTHY
Middle Name:J
Last Name:TEAGUE
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:16159 HAMILTON STATION RD
Mailing Address - Street 2:
Mailing Address - City:WATERFORD
Mailing Address - State:VA
Mailing Address - Zip Code:20197-1106
Mailing Address - Country:US
Mailing Address - Phone:703-587-7230
Mailing Address - Fax:
Practice Address - Street 1:16159 HAMILTON STATION RD
Practice Address - Street 2:
Practice Address - City:WATERFORD
Practice Address - State:VA
Practice Address - Zip Code:20197-1106
Practice Address - Country:US
Practice Address - Phone:703-587-7230
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0701001459101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA0701001459OtherPROFESSIONAL COUNSELOR