Healthcare Provider Details

I. General information

NPI: 1659819647
Provider Name (Legal Business Name): TEAL GROUP PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/09/2017
Last Update Date: 11/05/2020
Certification Date: 11/04/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

50 WEDDINGTON BRANCH RD
PIKEVILLE KY
41501-3296
US

IV. Provider business mailing address

258 NORTH LEVISA ROAD
MOUTHCARD KY
41548-8331
US

V. Phone/Fax

Practice location:
  • Phone: 606-437-2400
  • Fax: 606-437-2401
Mailing address:
  • Phone: 606-437-2400
  • Fax: 606-437-2401

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number103079
License Number StateKY
# 2
Primary TaxonomyN
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number103079
License Number StateKY
# 3
Primary TaxonomyN
Taxonomy Code207QA0401X
TaxonomyAddiction Medicine (Family Medicine) Physician
License Number02861
License Number StateKY
# 4
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number3009093
License Number StateKY
# 5
Primary TaxonomyY
Taxonomy Code207QA0401X
TaxonomyAddiction Medicine (Family Medicine) Physician
License Number02802
License Number StateKY

VIII. Authorized Official

Name: MS. SUZANNE FORD
Title or Position: PRESIDENT
Credential: DO
Phone: 606-437-2400