Healthcare Provider Details

I. General information

NPI: 1588281190
Provider Name (Legal Business Name): TERESA LYNETT LAUDERDALE LICDC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/30/2020
Last Update Date: 06/22/2023
Certification Date: 06/22/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

700 BRYDEN RD STE 128
COLUMBUS OH
43215-4839
US

IV. Provider business mailing address

296 CULLMAN RD
COLUMBUS OH
43207-3022
US

V. Phone/Fax

Practice location:
  • Phone: 614-462-0236
  • Fax:
Mailing address:
  • Phone: 614-462-0236
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License NumberLICDC.162303
License Number StateOH
# 2
Primary TaxonomyN
Taxonomy Code175T00000X
TaxonomyPeer Specialist
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: