MEDICARE: TERESHA KAYE ALLEN CADC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	101YA0400X	Addiction (Substance Use Disorder) Counselor	14080	IA

General Provider Information

NPI Number	:	1255845616
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	TERESHA KAYE ALLEN CADC

Provider Business Mailing Address
First Line	:	4014 KINGMAN BLVD
Second Line	:
City	:	DES MOINES
State	:	IA
Zip	:	50311-3516
Country	:	US
Telephone Number	:	515-661-5869
Fax Number	:	515-255-2359

Provider Business Practice Location Address
First Line	:	4014 KINGMAN BLVD
Second Line	:
City	:	DES MOINES
State	:	IA
Zip	:	50311-3516
Country	:	US
Telephone Number	:	515-661-5869
Fax Number	:	515-255-2359

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	11/21/2017
Last Update Date	:	11/21/2017

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