Provider Demographics
NPI:1093789828
Name:TEEPLES, KELLY LEE (MS IN EDUCATION)
Entity Type:Individual
Prefix:MS
First Name:KELLY
Middle Name:LEE
Last Name:TEEPLES
Suffix:
Gender:F
Credentials:MS IN EDUCATION
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1483 SW 18TH TER
Mailing Address - Street 2:
Mailing Address - City:FORT LAUDERDALE
Mailing Address - State:FL
Mailing Address - Zip Code:33312-4128
Mailing Address - Country:US
Mailing Address - Phone:786-423-1637
Mailing Address - Fax:
Practice Address - Street 1:1500 WESTON RD
Practice Address - Street 2:SUITE 211
Practice Address - City:WESTON
Practice Address - State:FL
Practice Address - Zip Code:33326-3263
Practice Address - Country:US
Practice Address - Phone:786-423-1637
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-02-16
Last Update Date:2013-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL1-04-1677103TB0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TB0200XBehavioral Health & Social Service ProvidersPsychologistCognitive & Behavioral
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL689927798Medicaid
FL689927796Medicaid