Healthcare Provider Details

I. General information

NPI: 1003905464
Provider Name (Legal Business Name): BRENDA LEA TEBAY M.A.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/12/2006
Last Update Date: 03/23/2020
Certification Date: 03/23/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1200 STEPHENSON AVE STE 400
PARKERSBURG WV
26101-4889
US

IV. Provider business mailing address

PO BOX 373
HARRISVILLE WV
26362-0373
US

V. Phone/Fax

Practice location:
  • Phone: 304-699-0506
  • Fax: 304-422-8850
Mailing address:
  • Phone: 304-643-4005
  • Fax: 304-643-4007

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103T00000X
TaxonomyPsychologist
License NumberWV 878
License Number StateWV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: