Provider Demographics
NPI:1407261969
Name:KELLEY, TERESA (CSW)
Entity Type:Individual
Prefix:
First Name:TERESA
Middle Name:
Last Name:KELLEY
Suffix:
Gender:F
Credentials:CSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3825 HENDERSON BLVD
Mailing Address - Street 2:405
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33629-5037
Mailing Address - Country:US
Mailing Address - Phone:713-252-0887
Mailing Address - Fax:877-957-3422
Practice Address - Street 1:350 ALTERNATE 19 NORTH
Practice Address - Street 2:SUITE C
Practice Address - City:PALM HARBOR
Practice Address - State:FL
Practice Address - Zip Code:34683-0000
Practice Address - Country:US
Practice Address - Phone:713-252-0887
Practice Address - Fax:888-345-7010
Is Sole Proprietor?:No
Enumeration Date:2014-06-24
Last Update Date:2014-06-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLISW-81681041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical