Basic Information
| Provider Information | |||||||||
| NPI: | 1740360882 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | KANG | ||||||||
| FirstName: | TERESA | ||||||||
| MiddleName: | J | ||||||||
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| Credential: | LCSW, LISAC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1243 W GLENMERE DR | ||||||||
| Address2: | |||||||||
| City: | CHANDLER | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 852247546 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4808212494 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1554 W VAN BUREN ST | ||||||||
| Address2: | |||||||||
| City: | PHOENIX | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 850072442 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6022586797 | ||||||||
| FaxNumber: | 6023409401 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/16/2006 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YA0400X | LISAC-10592 | AZ | X | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) | 1041C0700X | LCSW-3551 | AZ | X | Behavioral Health & Social Service Providers | Social Worker | Clinical |
ID Information
| ID | Type | State | Issuer | Description | 814716 | 01 | AZ | AHCCCS ID | OTHER |