Provider Demographics
NPI:1285157669
Name:TESORIERO, KALLIE (AUD)
Entity type:Individual
Prefix:
First Name:KALLIE
Middle Name:
Last Name:TESORIERO
Suffix:
Gender:F
Credentials:AUD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6035 FAIRVIEW RD
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28210-3256
Mailing Address - Country:US
Mailing Address - Phone:704-295-3000
Mailing Address - Fax:
Practice Address - Street 1:6035 FAIRVIEW RD
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28210-3256
Practice Address - Country:US
Practice Address - Phone:704-295-3000
Practice Address - Fax:704-295-3326
Is Sole Proprietor?:No
Enumeration Date:2017-07-18
Last Update Date:2024-12-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC4074231H00000X
NC12579231H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes231H00000XSpeech, Language and Hearing Service ProvidersAudiologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
8780919OtherCIGNA
SC1458532OtherWELLCARE OF SC
NC19R9SOtherBCBSNC
5647765OtherAETNA
NCQ57402AOtherMEDICARE-NC
NC1285157669Medicaid
SCSAN141Medicaid