Provider Demographics
NPI:1043462484
Name:PRIDDY, TERESA
Entity Type:Individual
Prefix:
First Name:TERESA
Middle Name:
Last Name:PRIDDY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6000 LAMAR AVE
Mailing Address - Street 2:STE 130
Mailing Address - City:MISSION
Mailing Address - State:KS
Mailing Address - Zip Code:66202-3234
Mailing Address - Country:US
Mailing Address - Phone:913-831-2550
Mailing Address - Fax:
Practice Address - Street 1:301 N MONROE ST
Practice Address - Street 2:
Practice Address - City:OLATHE
Practice Address - State:KS
Practice Address - Zip Code:66061-3162
Practice Address - Country:US
Practice Address - Phone:913-782-0283
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-10-16
Last Update Date:2009-12-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS7250104100000X
KSLMSW7588104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS1174513444Medicaid