Healthcare Provider Details

I. General information

NPI: 1669553319
Provider Name (Legal Business Name): TERESA S. PAINE PH. D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/18/2006
Last Update Date: 10/09/2024
Certification Date: 10/09/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

500 BLAND ST
BLUEFIELD WV
24701-3030
US

IV. Provider business mailing address

PO BOX 904
BLUEFIELD WV
24701-0904
US

V. Phone/Fax

Practice location:
  • Phone: 304-324-0999
  • Fax: 304-324-0996
Mailing address:
  • Phone: 304-324-0999
  • Fax: 304-324-0996

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number251
License Number StateWV
# 2
Primary TaxonomyN
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number0701001102
License Number StateVA
# 3
Primary TaxonomyN
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number0717000903
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: