Provider Demographics
NPI:1174874317
Name:POPPAS, TERESA JO (LCSW)
Entity type:Individual
Prefix:MS
First Name:TERESA
Middle Name:JO
Last Name:POPPAS
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12525 LAKE VISTA DR
Mailing Address - Street 2:
Mailing Address - City:GIBSONTON
Mailing Address - State:FL
Mailing Address - Zip Code:33534-3929
Mailing Address - Country:US
Mailing Address - Phone:813-220-4530
Mailing Address - Fax:
Practice Address - Street 1:3825 HENDERSON BLVD
Practice Address - Street 2:SUITE 304
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33629-5037
Practice Address - Country:US
Practice Address - Phone:813-220-4530
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-09-27
Last Update Date:2012-09-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSW105381041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical