Healthcare Provider Details

I. General information

NPI: 1447024617
Provider Name (Legal Business Name): CARSON TEAGUE PHD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/08/2023
Last Update Date: 02/03/2025
Certification Date: 02/03/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

261 MACK AVE STE 555
DETROIT MI
48201-2417
US

IV. Provider business mailing address

261 MACK AVE STE 555
DETROIT MI
48201-2417
US

V. Phone/Fax

Practice location:
  • Phone: 313-745-9763
  • Fax: 313-745-9854
Mailing address:
  • Phone: 313-745-9763
  • Fax: 313-745-9854

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103G00000X
TaxonomyClinical Neuropsychologist
License Number6301019342
License Number StateMI
# 2
Primary TaxonomyN
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number6301019342
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: