Provider Demographics
NPI:1699264275
Name:TELLAWI, GHAZEL
Entity type:Individual
Prefix:
First Name:GHAZEL
Middle Name:
Last Name:TELLAWI
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:317 N GREENWOOD AVE
Mailing Address - Street 2:
Mailing Address - City:MUNCIE
Mailing Address - State:IN
Mailing Address - Zip Code:47303-3611
Mailing Address - Country:US
Mailing Address - Phone:832-526-5419
Mailing Address - Fax:
Practice Address - Street 1:303 S PATERSON ST STE 1A
Practice Address - Street 2:
Practice Address - City:MADISON
Practice Address - State:WI
Practice Address - Zip Code:53703-4534
Practice Address - Country:US
Practice Address - Phone:608-571-0558
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-05-09
Last Update Date:2023-05-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNLP6552103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical