MEDICARE: MR. DANIEL STEPHEN TEATER LPC, M.DIV, MAC

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	101Y00000X	Counselor	2012029760	MO

General Provider Information

NPI Number	:	1992263248
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. DANIEL STEPHEN TEATER LPC, M.DIV, MAC

Provider Business Mailing Address
First Line	:	5947 WATERMAN BLVD
Second Line	:
City	:	SAINT LOUIS
State	:	MO
Zip	:	63112-1517
Country	:	US
Telephone Number	:	314-518-1616
Fax Number	:

Provider Business Practice Location Address
First Line	:	11780 BORMAN DR
Second Line	:
City	:	SAINT LOUIS
State	:	MO
Zip	:	63146-4135
Country	:	US
Telephone Number	:	314-479-9028
Fax Number	:	866-387-2869

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

Provider Enumeration Date	:	03/06/2019
Last Update Date	:	03/06/2019

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