Provider Demographics
NPI:1003142522
Name:TEDTAOTAO, DESTINY JEAN
Entity Type:Individual
Prefix:MRS
First Name:DESTINY
Middle Name:JEAN
Last Name:TEDTAOTAO
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 1:7600 AMBERGATE PL APT L202
Mailing Address - Street 2:
Mailing Address - City:RIVERSIDE
Mailing Address - State:CA
Mailing Address - Zip Code:92504-2659
Mailing Address - Country:US
Mailing Address - Phone:310-433-6338
Mailing Address - Fax:
Practice Address - Street 1:7600 AMBERGATE PL APT L202
Practice Address - Street 2:
Practice Address - City:RIVERSIDE
Practice Address - State:CA
Practice Address - Zip Code:92504-2659
Practice Address - Country:US
Practice Address - Phone:310-433-6338
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-10-19
Last Update Date:2009-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health