=====================================================
General NPI Number Information
=====================================================
NPI Number | 1629955158
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | TEAGHAN EVERARD
-----------------------------------------------------
Gender |
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/18/2025
-----------------------------------------------------
Last Update Date | 10/01/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2714 RIVERVIEW DR
-----------------------------------------------------
City | GREEN BAY
-----------------------------------------------------
State | WI
-----------------------------------------------------
Zip | 54313-6715
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 920-445-7377
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1313 SUN TERRACE ST
-----------------------------------------------------
City | LUXEMBURG
-----------------------------------------------------
State | WI
-----------------------------------------------------
Zip | 54217-1327
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YP2500X
-----------------------------------------------------
Taxonomy Name | Professional Counselor
-----------------------------------------------------
License Number | 10826-125
-----------------------------------------------------
License Number State | WI
-----------------------------------------------------