Basic Information
| Provider Information | |||||||||
| NPI: | 1215914742 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | RAY | ||||||||
| FirstName: | TERESA | ||||||||
| MiddleName: | CHILDRES | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | MA, NCC, LPC | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | RAY | ||||||||
| OtherFirstName: | TERRI | ||||||||
| OtherMiddleName: | C | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | MA, NCC, LPC | ||||||||
| OtherLastNameType: | 2 | ||||||||
| Mailing Information | |||||||||
| Address1: | PO BOX 3984 | ||||||||
| Address2: | |||||||||
| City: | GASTONIA | ||||||||
| State: | NC | ||||||||
| PostalCode: | 280540020 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7048618405 | ||||||||
| FaxNumber: | 7048650590 | ||||||||
| Practice Location | |||||||||
| Address1: | 258 E GARRISON BLVD | ||||||||
| Address2: | |||||||||
| City: | GASTONIA | ||||||||
| State: | NC | ||||||||
| PostalCode: | 280540460 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7048618405 | ||||||||
| FaxNumber: | 7048650590 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/27/2005 | ||||||||
| LastUpdateDate: | 07/09/2007 | ||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
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| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | X | ||||||||
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| AuthorizedOfficialNameSuffix: | |||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YP2500X | 2295 | NC | Y | Behavioral Health & Social Service Providers | Counselor | Professional |
ID Information
| ID | Type | State | Issuer | Description | B4131 | 01 | NC | MEDCOST.DOC ID # | OTHER | 6005064 | 05 | NC | MEDICAID | 0258G | 01 | NC | BCBS GROUP PIN | OTHER | 1039E | 01 | NC | BCBS PROVIDER PIN | OTHER | 6102251 | 05 | NC | MEDICAID | 7433388 | 01 | NC | AETNAGROUPBEHPIN | OTHER | 7361114 | 01 | NC | AETNA BEH.HEALTH PIN | OTHER |