MEDICARE: TERESA J KANG LCSW, LISAC

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	LISAC-10592	AZ
2	1041C0700X	Clinical Social Worker	LCSW-3551	AZ

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	814716	OTHER	AZ	AHCCCS ID

General Provider Information

NPI Number	:	1740360882
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	TERESA J KANG LCSW, LISAC

Provider Business Mailing Address
First Line	:	1243 W GLENMERE DR
Second Line	:
City	:	CHANDLER
State	:	AZ
Zip	:	85224-7546
Country	:	US
Telephone Number	:	480-821-2494
Fax Number	:

Provider Business Practice Location Address
First Line	:	1554 W VAN BUREN ST
Second Line	:
City	:	PHOENIX
State	:	AZ
Zip	:	85007-2442
Country	:	US
Telephone Number	:	602-258-6797
Fax Number	:	602-340-9401

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

Provider Enumeration Date	:	10/16/2006
Last Update Date	:	09/11/2025

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