Healthcare Provider Details

I. General information

NPI: 1407261969
Provider Name (Legal Business Name): TERESA KELLEY CSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/24/2014
Last Update Date: 06/24/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

350 ALTERNATE 19 NORTH SUITE C
PALM HARBOR FL
34683-0000
US

IV. Provider business mailing address

3825 HENDERSON BLVD 405
TAMPA FL
33629-5037
US

V. Phone/Fax

Practice location:
  • Phone: 713-252-0887
  • Fax: 888-345-7010
Mailing address:
  • Phone: 713-252-0887
  • Fax: 877-957-3422

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberISW-8168
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: