Provider Demographics
NPI:1134567589
Name:FENNELL, TERESA FATEMAH (MS LCSWA)
Entity type:Individual
Prefix:MS
First Name:TERESA
Middle Name:FATEMAH
Last Name:FENNELL
Suffix:
Gender:F
Credentials:MS LCSWA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12506 ATKINS CIRCLE DR
Mailing Address - Street 2:APT 320
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28277-0037
Mailing Address - Country:US
Mailing Address - Phone:704-726-3885
Mailing Address - Fax:
Practice Address - Street 1:8801 J M KEYNES DR
Practice Address - Street 2:SUITE 440
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28262-8436
Practice Address - Country:US
Practice Address - Phone:704-537-9551
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-06-07
Last Update Date:2013-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCP0071681041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical