Provider Demographics
NPI:1447090212
Name:TEDDER, MIAH
Entity type:Individual
Prefix:
First Name:MIAH
Middle Name:
Last Name:TEDDER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4093 DUNKIRK DR
Mailing Address - Street 2:
Mailing Address - City:BURLINGTON
Mailing Address - State:NC
Mailing Address - Zip Code:27215-0106
Mailing Address - Country:US
Mailing Address - Phone:919-408-6224
Mailing Address - Fax:
Practice Address - Street 1:2004 SPRING CREEK DR
Practice Address - Street 2:
Practice Address - City:DURHAM
Practice Address - State:NC
Practice Address - Zip Code:27704-4795
Practice Address - Country:US
Practice Address - Phone:919-408-6224
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-05-29
Last Update Date:2024-05-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCP0205731041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical