Provider Demographics
NPI:1902874209
Name:TEETER, GARRY DEAN
Entity Type:Individual
Prefix:
First Name:GARRY
Middle Name:DEAN
Last Name:TEETER
Suffix:
Gender:M
Credentials:
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 298
Mailing Address - Street 2:
Mailing Address - City:BRYANT
Mailing Address - State:AR
Mailing Address - Zip Code:72089-0298
Mailing Address - Country:US
Mailing Address - Phone:501-847-2229
Mailing Address - Fax:501-847-8608
Practice Address - Street 1:200 N MARKET ST
Practice Address - Street 2:
Practice Address - City:BENTON
Practice Address - State:AR
Practice Address - Zip Code:72015-3733
Practice Address - Country:US
Practice Address - Phone:501-847-2229
Practice Address - Fax:501-847-8608
Is Sole Proprietor?:Yes
Enumeration Date:2006-03-10
Last Update Date:2011-04-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARP9903009101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health