1093466872 NPI number — MS. SHELBY COSHETTA TEASLEY QMHP-A,C

Table of content: MS. SHELBY COSHETTA TEASLEY QMHP-A,C (NPI 1093466872)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1093466872 NPI number — MS. SHELBY COSHETTA TEASLEY QMHP-A,C

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
TEASLEY
Provider First Name:
SHELBY
Provider Middle Name:
COSHETTA
Provider Name Prefix Text:
MS.
Provider Name Suffix Text:
Provider Credential Text:
QMHP-A,C
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
BREEDLOVE
Provider Other First Name:
WAYNE
Provider Other Middle Name:
Provider Other Name Prefix Text:
MR.
Provider Other Name Suffix Text:
Provider Other Credential Text:
QMHP,A,C
Provider Other Last Name Type Code:
2

NPI Number Information

NPI Number:
1093466872
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
01/13/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
7300 HANOVER GREEN DR STE 300-A
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MECHANICSVILLE
Provider Business Mailing Address State Name:
VA
Provider Business Mailing Address Postal Code:
23111-1705
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
804-497-9064
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
7300 HANOVER GREEN DR STE 300-A
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MECHANICSVILLE
Provider Business Practice Location Address State Name:
VA
Provider Business Practice Location Address Postal Code:
23111-1705
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
804-497-9064
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
01/13/2022

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 101YP2500X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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