Provider Demographics
NPI:1790249316
Name:TELLEZ, ANGELA LYNN
Entity Type:Individual
Prefix:
First Name:ANGELA
Middle Name:LYNN
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 1:2563 KENTWOOD CT
Mailing Address - Street 2:
Mailing Address - City:LAS CRUCES
Mailing Address - State:NM
Mailing Address - Zip Code:88011-4326
Mailing Address - Country:US
Mailing Address - Phone:575-496-5775
Mailing Address - Fax:
Practice Address - Street 1:755 S TELSHOR BLVD STE 201B
Practice Address - Street 2:
Practice Address - City:LAS CRUCES
Practice Address - State:NM
Practice Address - Zip Code:88011-3647
Practice Address - Country:US
Practice Address - Phone:575-323-0940
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-01-28
Last Update Date:2019-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMX-10891104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker