Basic Information
| Provider Information | |||||||||
| NPI: | 1528392412 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | TEISL | ||||||||
| FirstName: | MICHAEL | ||||||||
| MiddleName: | JOHN | ||||||||
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| Credential: | PHD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 601 ELMWOOD AVE | ||||||||
| Address2: | BOX: PSYCH | ||||||||
| City: | ROCHESTER | ||||||||
| State: | NY | ||||||||
| PostalCode: | 146420001 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5852755228 | ||||||||
| FaxNumber: | 5852760161 | ||||||||
| Practice Location | |||||||||
| Address1: | 300 CRITTENDEN BLVD | ||||||||
| Address2: | |||||||||
| City: | ROCHESTER | ||||||||
| State: | NY | ||||||||
| PostalCode: | 146420001 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5852755228 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 09/24/2009 | ||||||||
| LastUpdateDate: | 03/29/2011 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103TC0700X | 018295 | NY | N | Behavioral Health & Social Service Providers | Psychologist | Clinical | 103TC0700X | 0182951 | NY | Y | Behavioral Health & Social Service Providers | Psychologist | Clinical |
ID Information
| ID | Type | State | Issuer | Description | 03166718 | 05 | NY | MEDICAID |