MEDICARE: TERESA CHILDRES RAY MA, NCC, LPC

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	101YP2500X	Professional Counselor	2295	NC

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	B4131	OTHER	NC	MEDCOST.DOC ID #
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
3	0258G	OTHER	NC	BCBS GROUP PIN
4	1039E	OTHER	NC	BCBS PROVIDER PIN
5	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
6	7433388	OTHER	NC	AETNAGROUPBEHPIN
7	7361114	OTHER	NC	AETNA BEH.HEALTH PIN

General Provider Information

NPI Number	:	1215914742
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	TERESA CHILDRES RAY MA, NCC, LPC

Provider Business Mailing Address
First Line	:	PO BOX 3984
Second Line	:
City	:	GASTONIA
State	:	NC
Zip	:	28054-0020
Country	:	US
Telephone Number	:	704-861-8405
Fax Number	:	704-865-0590

Provider Business Practice Location Address
First Line	:	258 E GARRISON BLVD
Second Line	:
City	:	GASTONIA
State	:	NC
Zip	:	28054-0460
Country	:	US
Telephone Number	:	704-861-8405
Fax Number	:	704-865-0590

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	12/27/2005
Last Update Date	:	07/09/2007

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Directions to “ TERESA CHILDRES RAY MA, NCC, LPC” Practice Location

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