Basic Information
| Provider Information | |||||||||
| NPI: | 1033279765 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | KEY-PICIUCCO | ||||||||
| FirstName: | TERESA | ||||||||
| MiddleName: | A. | ||||||||
| NamePrefix: | MS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | PYSCH ASSISTANT | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 68 W CHURCH ST STE 318 | ||||||||
| Address2: | |||||||||
| City: | NEWARK | ||||||||
| State: | OH | ||||||||
| PostalCode: | 430555050 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7402811777 | ||||||||
| FaxNumber: | 7402811778 | ||||||||
| Practice Location | |||||||||
| Address1: | 68 W CHURCH ST STE 318 | ||||||||
| Address2: | |||||||||
| City: | NEWARK | ||||||||
| State: | OH | ||||||||
| PostalCode: | 430555050 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7402811777 | ||||||||
| FaxNumber: | 7402811778 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/11/2006 | ||||||||
| LastUpdateDate: | 11/24/2020 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 11/16/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103TC0700X | 821 | WV | N | Behavioral Health & Social Service Providers | Psychologist | Clinical | 101YP2500X | 1291 | WV | Y | Behavioral Health & Social Service Providers | Counselor | Professional |
ID Information
| ID | Type | State | Issuer | Description | 588982000 | 01 | WV | MAGELLAN MIS NUMBER | OTHER | Y01291 | 01 | WV | HEALTH PLAN ID | OTHER | 0005456001 | 05 | WV | MEDICAID | 001719061 | 01 | WV | MSBCBS SERVICE ID | OTHER | 2171255 | 01 | WV | CIGNA ID NUMBER | OTHER |