Provider Demographics
NPI:1013640861
Name:MCELVAIN, TEDDI LYNN (R1464950422)
Entity Type:Individual
Prefix:
First Name:TEDDI
Middle Name:LYNN
Last Name:MCELVAIN
Suffix:
Gender:F
Credentials:R1464950422
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6096 RIVERSIDE AVE APT 33
Mailing Address - Street 2:
Mailing Address - City:RIVERSIDE
Mailing Address - State:CA
Mailing Address - Zip Code:92506-2111
Mailing Address - Country:US
Mailing Address - Phone:760-275-7037
Mailing Address - Fax:
Practice Address - Street 1:4750 PALM AVE
Practice Address - Street 2:
Practice Address - City:RIVERSIDE
Practice Address - State:CA
Practice Address - Zip Code:92501-4012
Practice Address - Country:US
Practice Address - Phone:951-686-0021
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-07-07
Last Update Date:2022-07-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAR1464950422101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAR1464950422OtherCCAPP