Provider Demographics
NPI:1417438615
Name:TELLEZ, IMELDA
Entity Type:Individual
Prefix:
First Name:IMELDA
Middle Name:
Last Name:TELLEZ
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 1:2116 44TH RD
Mailing Address - Street 2:
Mailing Address - City:LONG ISLAND CITY
Mailing Address - State:NY
Mailing Address - Zip Code:11101-5011
Mailing Address - Country:US
Mailing Address - Phone:718-937-4270
Mailing Address - Fax:
Practice Address - Street 1:2116 44TH RD
Practice Address - Street 2:
Practice Address - City:LONG ISLAND CITY
Practice Address - State:NY
Practice Address - Zip Code:11101-5011
Practice Address - Country:US
Practice Address - Phone:718-937-4270
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-08-25
Last Update Date:2019-09-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health