Provider Demographics
NPI:1679694947
Name:KESTLY, THERESA A (PHD)
Entity type:Individual
Prefix:DR
First Name:THERESA
Middle Name:A
Last Name:KESTLY
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 800
Mailing Address - Street 2:
Mailing Address - City:CORRALES
Mailing Address - State:NM
Mailing Address - Zip Code:87048-0800
Mailing Address - Country:US
Mailing Address - Phone:505-898-1177
Mailing Address - Fax:505-792-3551
Practice Address - Street 1:4686 CORRALES RD
Practice Address - Street 2:
Practice Address - City:CORRALES
Practice Address - State:NM
Practice Address - Zip Code:87048-8610
Practice Address - Country:US
Practice Address - Phone:505-898-1177
Practice Address - Fax:505-792-3551
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-03
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM517103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist