MEDICARE: MILICIA TEDDER

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	251S00000X	Community/Behavioral Health Agency	3735	NC

General Provider Information

NPI Number	:	1013335348
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MILICIA TEDDER

Provider Business Mailing Address
First Line	:	2004 SPRING CREEK DR
Second Line	:
City	:	DURHAM
State	:	NC
Zip	:	27704-4795
Country	:	US
Telephone Number	:	919-697-1674
Fax Number	:

Provider Business Practice Location Address
First Line	:	2004 SPRING CREEK DR
Second Line	:
City	:	DURHAM
State	:	NC
Zip	:	27704-4795
Country	:	US
Telephone Number	:	919-697-1674
Fax Number	:

Authorized Official
Title or Position	:	LICENSED PSYCHOLOGICAL ASSOCIATE
Name	:	MILICIA TEDDER
Credential	:
Telephone Number	:	919-697-1674

Provider Enumeration Date	:	04/03/2014
Last Update Date	:	04/03/2014

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