Basic Information
| Provider Information | |||||||||
| NPI: | 1427448166 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MEDEIROS | ||||||||
| FirstName: | TEIRNEY | ||||||||
| MiddleName: | |||||||||
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| Credential: | LPC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 417 RACETRACK RD NW | ||||||||
| Address2: | |||||||||
| City: | FORT WALTON BEACH | ||||||||
| State: | FL | ||||||||
| PostalCode: | 325474612 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8508642273 | ||||||||
| FaxNumber: | 8508626270 | ||||||||
| Practice Location | |||||||||
| Address1: | 1401 OLD STATE SCHOOL ROAD | ||||||||
| Address2: | |||||||||
| City: | GATESVILLE | ||||||||
| State: | TX | ||||||||
| PostalCode: | 765994612 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2546541796 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/03/2015 | ||||||||
| LastUpdateDate: | 04/01/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 04/01/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YM0800X | 77929 | TX | Y | Behavioral Health & Social Service Providers | Counselor | Mental Health |
No ID Information.