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General NPI Number Information
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NPI Number | 1376823526
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Entity Type | Individual
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Provider Name | LARRY JAMES TEDDER CDP
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Gender | Male
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Dates
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Enumeration Date | 08/19/2011
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Last Update Date | 11/21/2019
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Provider Practice Location Address
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Address Line | 305 PACIFIC AVE S STE 102
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City | KELSO
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State | WA
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Zip | 98626-1638
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Country | US
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Telephone | 360-577-7442
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Fax | 360-577-7904
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Provider Business Mailing Address
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Address Line | PO BOX 1847
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City | LONGVIEW
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State | WA
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Zip | 98632-8140
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Country | US
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Telephone | 360-423-0203
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Fax | 360-577-0269
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 101YA0400X
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Taxonomy Name | Addiction (Substance Use Disorder) Counselor
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License Number | 00001495
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License Number State | WA
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