Provider Demographics
NPI:1013043231
Name:BURBACH, TERESA
Entity Type:Individual
Prefix:
First Name:TERESA
Middle Name:
Last Name:BURBACH
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 1:210 SO. DELACEY AVE
Mailing Address - Street 2:
Mailing Address - City:PASADENA
Mailing Address - State:CA
Mailing Address - Zip Code:91105
Mailing Address - Country:US
Mailing Address - Phone:616-510-8625
Mailing Address - Fax:
Practice Address - Street 1:44847 SIERRA HWY
Practice Address - Street 2:
Practice Address - City:LANCASTER
Practice Address - State:CA
Practice Address - Zip Code:93534-3226
Practice Address - Country:US
Practice Address - Phone:661-510-8625
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-23
Last Update Date:2023-12-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMCMF0209801106H00000X
CA402838106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist