MEDICARE: MISS DALORIA TEAGUE LCSW

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	101YA0400X	Addiction (Substance Use Disorder) Counselor
2	1041C0700X	Clinical Social Worker

General Provider Information

NPI Number	:	1528395050
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MISS DALORIA TEAGUE LCSW

Provider Business Mailing Address
First Line	:	PO BOX 5054
Second Line	:
City	:	CHARLOTTE
State	:	NC
Zip	:	28299-5054
Country	:	US
Telephone Number	:	704-819-9312
Fax Number	:

Provider Business Practice Location Address
First Line	:	4037 E INDEPENDENCE BLVD BLDG SUITE100
Second Line	:
City	:	CHARLOTTE
State	:	NC
Zip	:	28205-3260
Country	:	US
Telephone Number	:	704-523-5775
Fax Number	:

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

Provider Enumeration Date	:	11/04/2009
Last Update Date	:	12/05/2024

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