Provider Demographics
NPI:1740360882
Name:KANG, TERESA J (LCSW, LISAC)
Entity type:Individual
Prefix:
First Name:TERESA
Middle Name:J
Last Name:KANG
Suffix:
Gender:F
Credentials:LCSW, LISAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1243 W GLENMERE DR
Mailing Address - Street 2:
Mailing Address - City:CHANDLER
Mailing Address - State:AZ
Mailing Address - Zip Code:85224-7546
Mailing Address - Country:US
Mailing Address - Phone:480-821-2494
Mailing Address - Fax:
Practice Address - Street 1:1554 W VAN BUREN ST
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85007-2442
Practice Address - Country:US
Practice Address - Phone:602-258-6797
Practice Address - Fax:602-340-9401
Is Sole Proprietor?:No
Enumeration Date:2006-10-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZLISAC-10592101YA0400X
AZLCSW-35511041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Not Answered1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ814716OtherAHCCCS ID