Provider Demographics
NPI:1699988709
Name:GEORGE, TERESA MORI (MSW, LICSW)
Entity type:Individual
Prefix:
First Name:TERESA
Middle Name:MORI
Last Name:GEORGE
Suffix:
Gender:F
Credentials:MSW, LICSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1820 HAMPSHIRE LN N
Mailing Address - Street 2:
Mailing Address - City:GOLDEN VALLEY
Mailing Address - State:MN
Mailing Address - Zip Code:55427-4219
Mailing Address - Country:US
Mailing Address - Phone:763-226-6591
Mailing Address - Fax:763-428-6314
Practice Address - Street 1:14165 JAMES RD
Practice Address - Street 2:
Practice Address - City:ROGERS
Practice Address - State:MN
Practice Address - Zip Code:55374-9317
Practice Address - Country:US
Practice Address - Phone:763-428-6330
Practice Address - Fax:763-428-6314
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-07
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN047751041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN80001683Medicare ID - Type UnspecifiedINDIVIDUAL PROVIDER NUMBE