Provider Demographics
NPI:1184086720
Name:TEAGUE, THOMAS JEREMIAH JR
Entity type:Individual
Prefix:MR
First Name:THOMAS
Middle Name:JEREMIAH
Last Name:TEAGUE
Suffix:JR
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 1:360 S GRANT AVE
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:OH
Mailing Address - Zip Code:43215-5537
Mailing Address - Country:US
Mailing Address - Phone:614-593-6426
Mailing Address - Fax:614-467-9512
Practice Address - Street 1:1515 E BROAD ST
Practice Address - Street 2:889 E, BROAD ST
Practice Address - City:COLUMBUS
Practice Address - State:OH
Practice Address - Zip Code:43205-1550
Practice Address - Country:US
Practice Address - Phone:614-251-7723
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-03-23
Last Update Date:2025-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHICDC.965668-CS101YA0400X
OH965668101YA0400X
OHS.00144211041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
OHICDC.965668-CSOtherLICENSED INDEPENDENT CHEMICAL DEPENDENCY COUNSELOR CLINICAL SUPERVISOR