Provider Demographics
NPI:1679607238
Name:GONELLA, TEALAI RAECHAL
Entity Type:Individual
Prefix:
First Name:TEALAI
Middle Name:RAECHAL
Last Name:GONELLA
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 1:18330 N 79TH AVE APT 1048
Mailing Address - Street 2:
Mailing Address - City:GLENDALE
Mailing Address - State:AZ
Mailing Address - Zip Code:85308-8345
Mailing Address - Country:US
Mailing Address - Phone:602-516-4188
Mailing Address - Fax:
Practice Address - Street 1:18330 N 79TH AVE APT 1048
Practice Address - Street 2:
Practice Address - City:GLENDALE
Practice Address - State:AZ
Practice Address - Zip Code:85308-8345
Practice Address - Country:US
Practice Address - Phone:602-516-4188
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-15
Last Update Date:2007-07-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist