Healthcare Provider Details

I. General information

NPI: 1225289010
Provider Name (Legal Business Name): TERESA L HIATT BGS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/10/2008
Last Update Date: 10/10/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

118 N SALLY DR
WINAMAC IN
46996-9100
US

IV. Provider business mailing address

118 N SALLY DR
WINAMAC IN
46996-9100
US

V. Phone/Fax

Practice location:
  • Phone: 574-946-4233
  • Fax: 574-946-4365
Mailing address:
  • Phone: 574-946-4233
  • Fax: 574-946-4365

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: