Provider Demographics
NPI:1275143646
Name:PHELAN, TERESA
Entity Type:Individual
Prefix:
First Name:TERESA
Middle Name:
Last Name:PHELAN
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:UMASS MEMORIAL MEDICAL CENTER
Mailing Address - Street 2:55 LAKE AVENUE NORTH, PSYCHIATRY
Mailing Address - City:WORCESTER
Mailing Address - State:MA
Mailing Address - Zip Code:01655
Mailing Address - Country:US
Mailing Address - Phone:508-334-1000
Mailing Address - Fax:
Practice Address - Street 1:UMASS MEMORIAL MEDICAL CENTER
Practice Address - Street 2:55 LAKE AVENUE NORTH, PSYCHIATRY
Practice Address - City:WORCESTER
Practice Address - State:MA
Practice Address - Zip Code:01655
Practice Address - Country:US
Practice Address - Phone:508-334-1000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-07-31
Last Update Date:2020-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA0148RC175T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175T00000XOther Service ProvidersPeer Specialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA0148RCOtherRECOVERY COACH CERTIFICATION