Provider Demographics
NPI:1033279765
Name:KEY-PICIUCCO, TERESA A (PYSCH ASSISTANT)
Entity Type:Individual
Prefix:MS
First Name:TERESA
Middle Name:A
Last Name:KEY-PICIUCCO
Suffix:
Gender:F
Credentials:PYSCH ASSISTANT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:68 W CHURCH ST STE 318
Mailing Address - Street 2:
Mailing Address - City:NEWARK
Mailing Address - State:OH
Mailing Address - Zip Code:43055-5050
Mailing Address - Country:US
Mailing Address - Phone:740-281-1777
Mailing Address - Fax:740-281-1778
Practice Address - Street 1:68 W CHURCH ST STE 318
Practice Address - Street 2:
Practice Address - City:NEWARK
Practice Address - State:OH
Practice Address - Zip Code:43055-5050
Practice Address - Country:US
Practice Address - Phone:740-281-1777
Practice Address - Fax:740-281-1778
Is Sole Proprietor?:No
Enumeration Date:2006-12-11
Last Update Date:2020-11-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV821103TC0700X
WV1291101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV588982000OtherMAGELLAN MIS NUMBER
WVY01291OtherHEALTH PLAN ID
WV0005456001Medicaid
WV001719061OtherMSBCBS SERVICE ID
WV2171255OtherCIGNA ID NUMBER
WV0005456001Medicaid