MEDICARE: GHAZEL TELLAWI PHD

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	103TC0700X	Clinical Psychologist	LP6552	MN
2	103TC0700X	Clinical Psychologist	3854-57	WI
3	103TC0700X	Clinical Psychologist	285496	KY

General Provider Information

NPI Number	:	1699264275
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	GHAZEL TELLAWI PHD

Provider Business Mailing Address
First Line	:	1979 RICHMOND DR STE 1
Second Line	:
City	:	LOUISVILLE
State	:	KY
Zip	:	40205-1411
Country	:	US
Telephone Number	:	612-234-1834
Fax Number	:

Provider Business Practice Location Address
First Line	:	1979 RICHMOND DR STE 1
Second Line	:
City	:	LOUISVILLE
State	:	KY
Zip	:	40205-1411
Country	:	US
Telephone Number	:	612-234-1834
Fax Number	:

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

Provider Enumeration Date	:	05/09/2018
Last Update Date	:	08/27/2025

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