Provider Demographics
NPI:1548508484
Name:TEAGUE, JULIA E (OTR)
Entity type:Individual
Prefix:
First Name:JULIA
Middle Name:E
Last Name:TEAGUE
Suffix:
Gender:F
Credentials:OTR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3727 ROSE LAKE DR
Mailing Address - Street 2:SUITE 103
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28217-2846
Mailing Address - Country:US
Mailing Address - Phone:704-778-7192
Mailing Address - Fax:
Practice Address - Street 1:3727 ROSE LAKE DR
Practice Address - Street 2:SUITE 103
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28217-2846
Practice Address - Country:US
Practice Address - Phone:704-778-7192
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-01-28
Last Update Date:2013-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC8516225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC225X00000XMedicaid