=====================================================
General NPI Number Information
=====================================================
NPI Number | 1730155185
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | SANDRA TEUBER
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/27/2006
-----------------------------------------------------
Last Update Date | 06/17/2008
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2900 VETERANS WAY
-----------------------------------------------------
City | VIERA
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32940-8007
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 321-637-3788
-----------------------------------------------------
Fax | 321-637-3648
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2808 STEARNS AVE NE
-----------------------------------------------------
City | PALM BAY
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32905-3542
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 321-768-7534
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | LICENSED CLINICAL SOCIAL WORKER
-----------------------------------------------------
Name | MS. SANDRA LEE BOUCHARD TEUBER
-----------------------------------------------------
Credential | LCSW, CAP
-----------------------------------------------------
Telephone | 321-637-3788
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YA0400X
-----------------------------------------------------
Taxonomy Name | Addiction (Substance Use Disorder) Counselor
-----------------------------------------------------
License Number | CAP 2661
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 1041C0700X
-----------------------------------------------------
Taxonomy Name | Clinical Social Worker
-----------------------------------------------------
License Number | SW 7842
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------