Provider Demographics
NPI:1447024617
Name:TEAGUE, CARSON (PHD)
Entity type:Individual
Prefix:
First Name:CARSON
Middle Name:
Last Name:TEAGUE
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:261 MACK AVE STE 555
Mailing Address - Street 2:
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48201-2417
Mailing Address - Country:US
Mailing Address - Phone:313-745-9763
Mailing Address - Fax:313-745-9854
Practice Address - Street 1:261 MACK AVE STE 555
Practice Address - Street 2:
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48201-2417
Practice Address - Country:US
Practice Address - Phone:313-745-9763
Practice Address - Fax:313-745-9854
Is Sole Proprietor?:Yes
Enumeration Date:2023-11-08
Last Update Date:2025-02-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6301019342103T00000X, 103G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103G00000XBehavioral Health & Social Service ProvidersClinical Neuropsychologist
No103T00000XBehavioral Health & Social Service ProvidersPsychologist