Healthcare Provider Details

I. General information

NPI: 1992272389
Provider Name (Legal Business Name): TEGAN MICHL PSYD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/24/2018
Last Update Date: 10/24/2023
Certification Date: 10/24/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

NEUE AMBERGER STR
GRAFENWOEHR BAVARIA
92655
DE

IV. Provider business mailing address

9040 FITZSIMMONS DR
JOINT BASE LEWIS MCCHORD WA
98431-1000
US

V. Phone/Fax

Practice location:
  • Phone: 314-590-3134
  • Fax:
Mailing address:
  • Phone: 253-968-2820
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License NumberPY61035725
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: