Provider Demographics
NPI:1730355017
Name:DICK, G TEAL (MDIV LPC-S)
Entity type:Individual
Prefix:
First Name:G
Middle Name:TEAL
Last Name:DICK
Suffix:
Gender:M
Credentials:MDIV LPC-S
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:P.O. BOX 55
Mailing Address - Street 2:
Mailing Address - City:THORSBY
Mailing Address - State:AL
Mailing Address - Zip Code:35171-3428
Mailing Address - Country:US
Mailing Address - Phone:205-389-2079
Mailing Address - Fax:
Practice Address - Street 1:1881 COUNTY ROAD 627
Practice Address - Street 2:
Practice Address - City:THORSBY
Practice Address - State:AL
Practice Address - Zip Code:35171-8151
Practice Address - Country:US
Practice Address - Phone:205-389-2079
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-05-06
Last Update Date:2014-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL1489101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
11812892OtherCAQH
AL515-45395OtherBLUE CROSS BLUE SHIELD