Provider Demographics
NPI:1770323966
Name:TELLEZ, IRENE
Entity type:Individual
Prefix:
First Name:IRENE
Middle Name:
Last Name:TELLEZ
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2726 HEIDLEBURG LN
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28210-7665
Mailing Address - Country:US
Mailing Address - Phone:704-975-8578
Mailing Address - Fax:
Practice Address - Street 1:5215 RANDOLPH RD
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28211-5160
Practice Address - Country:US
Practice Address - Phone:980-999-4595
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-05-28
Last Update Date:2025-03-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCP13250225100000X
VACP042483T225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist