Healthcare Provider Details

I. General information

NPI: 1255446498
Provider Name (Legal Business Name): TERESA JO STUART LSCSW, LCAC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/20/2006
Last Update Date: 04/27/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 MILITARY AVE SUITE 116
DODGE CITY KS
67801-4946
US

IV. Provider business mailing address

PO BOX 602
BUCKLIN KS
67834-0602
US

V. Phone/Fax

Practice location:
  • Phone: 620-338-2168
  • Fax: 620-225-1311
Mailing address:
  • Phone: 620-338-2168
  • Fax: 620-225-1311

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberLSCSW 2135
License Number StateKS
# 2
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License NumberLCAC 186
License Number StateKS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: