Provider Demographics
NPI:1366807307
Name:TEAGUE, WILL JUSTIN (MA LLP CAADC)
Entity type:Individual
Prefix:MR
First Name:WILL
Middle Name:JUSTIN
Last Name:TEAGUE
Suffix:
Gender:M
Credentials:MA LLP CAADC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:23636 MICHIGAN AVE # 547
Mailing Address - Street 2:
Mailing Address - City:DEARBORN
Mailing Address - State:MI
Mailing Address - Zip Code:48124-1910
Mailing Address - Country:US
Mailing Address - Phone:248-943-0084
Mailing Address - Fax:
Practice Address - Street 1:30375 NORTHWESTERN HWY
Practice Address - Street 2:STE. 200
Practice Address - City:FARMINGTON HILLS
Practice Address - State:MI
Practice Address - Zip Code:48334-3297
Practice Address - Country:US
Practice Address - Phone:248-943-0084
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-12-17
Last Update Date:2015-12-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6301013275103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist