Provider Demographics
NPI:1922333236
Name:TELLEZ, VICTORIA JEAN (MSW)
Entity Type:Individual
Prefix:MRS
First Name:VICTORIA
Middle Name:JEAN
Last Name:TELLEZ
Suffix:
Gender:F
Credentials:MSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:909 LONG DR STE A
Mailing Address - Street 2:
Mailing Address - City:SHERIDAN
Mailing Address - State:WY
Mailing Address - Zip Code:82801-3282
Mailing Address - Country:US
Mailing Address - Phone:307-675-1805
Mailing Address - Fax:
Practice Address - Street 1:565 BROOKIE PATH
Practice Address - Street 2:
Practice Address - City:SHERIDAN
Practice Address - State:WY
Practice Address - Zip Code:82801-8921
Practice Address - Country:US
Practice Address - Phone:307-752-7537
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-10-05
Last Update Date:2021-07-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WY251C00000X
WY11801041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No251C00000XAgenciesDay Training, Developmentally Disabled Services