Provider Demographics
NPI:1548330145
Name:FAILLACE, TERESA (LCSW)
Entity type:Individual
Prefix:
First Name:TERESA
Middle Name:
Last Name:FAILLACE
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 183
Mailing Address - Street 2:
Mailing Address - City:FLORENCE
Mailing Address - State:OR
Mailing Address - Zip Code:97439
Mailing Address - Country:US
Mailing Address - Phone:541-997-6452
Mailing Address - Fax:541-997-6452
Practice Address - Street 1:1495 W 8TH STREET
Practice Address - Street 2:
Practice Address - City:FLORENCE
Practice Address - State:OR
Practice Address - Zip Code:97439-0007
Practice Address - Country:US
Practice Address - Phone:541-997-6452
Practice Address - Fax:541-997-6452
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-09
Last Update Date:2013-10-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OROR2025103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ORSC268890Medicaid
ORSC268890Medicaid