MEDICARE: CONSULTING PSYCHOLOGICAL RESOURCES, LLC

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	103T00000X	Psychologist

General Provider Information

NPI Number	:	1033254529
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	CONSULTING PSYCHOLOGICAL RESOURCES, LLC

Provider Business Mailing Address
First Line	:	1907 PASS RD
Second Line	:	SUITE G
City	:	BILOXI
State	:	MS
Zip	:	39531-4101
Country	:	US
Telephone Number	:	228-594-9010
Fax Number	:	228-594-9012

Provider Business Practice Location Address
First Line	:	1907 PASS RD
Second Line	:	SUITE G
City	:	BILOXI
State	:	MS
Zip	:	39531-4101
Country	:	US
Telephone Number	:	228-594-9010
Fax Number	:	228-594-9012

Authorized Official
Title or Position	:	OWNER
Name	:	DR. JULIE TEATER
Credential	:	PSY.D.
Telephone Number	:	228-594-9010

Provider Enumeration Date	:	02/21/2007
Last Update Date	:	12/09/2013

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Practice Location Address:

1907 PASS RD , SUITE G
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39531-4101

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1346490521 — MRS. JENNIFER M MAYNE LCSW
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