Provider Demographics
NPI:1316085582
Name:KTEILY, AUDREY ELLEN (LPC-S)
Entity type:Individual
Prefix:DR
First Name:AUDREY
Middle Name:ELLEN
Last Name:KTEILY
Suffix:
Gender:F
Credentials:LPC-S
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:743 W MAIN ST
Mailing Address - Street 2:
Mailing Address - City:COPPELL
Mailing Address - State:TX
Mailing Address - Zip Code:75019-4744
Mailing Address - Country:US
Mailing Address - Phone:972-304-0700
Mailing Address - Fax:972-692-5844
Practice Address - Street 1:743 W MAIN ST
Practice Address - Street 2:
Practice Address - City:COPPELL
Practice Address - State:TX
Practice Address - Zip Code:75019-4744
Practice Address - Country:US
Practice Address - Phone:972-304-0700
Practice Address - Fax:972-692-5844
Is Sole Proprietor?:No
Enumeration Date:2007-02-01
Last Update Date:2024-11-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX17316101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX17316OtherLPC