Basic Information
| Provider Information | |||||||||
| NPI: | 1730155185 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | SANDRA TEUBER | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2808 STEARNS AVE NE | ||||||||
| Address2: | |||||||||
| City: | PALM BAY | ||||||||
| State: | FL | ||||||||
| PostalCode: | 329053542 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3217687534 | ||||||||
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| Practice Location | |||||||||
| Address1: | 2900 VETERANS WAY | ||||||||
| Address2: | |||||||||
| City: | VIERA | ||||||||
| State: | FL | ||||||||
| PostalCode: | 329408007 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3216373788 | ||||||||
| FaxNumber: | 3216373648 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/27/2006 | ||||||||
| LastUpdateDate: | 06/17/2008 | ||||||||
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| AuthorizedOfficialLastName: | TEUBER | ||||||||
| AuthorizedOfficialFirstName: | SANDRA | ||||||||
| AuthorizedOfficialMiddleName: | LEE BOUCHARD | ||||||||
| AuthorizedOfficialTitleorPosition: | LICENSED CLINICAL SOCIAL WORKER | ||||||||
| AuthorizedOfficialTelephone: | 3216373788 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MS. | ||||||||
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| AuthorizedOfficialCredential: | LCSW, CAP | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YA0400X | CAP 2661 | FL | N | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) | 1041C0700X | SW 7842 | FL | Y | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Social Worker | Clinical |
No ID Information.