Provider Demographics
NPI:1023358306
Name:SERRANO, TERESA
Entity Type:Individual
Prefix:
First Name:TERESA
Middle Name:
Last Name:SERRANO
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 1:420 N MCKINLEY ST # 111-428
Mailing Address - Street 2:
Mailing Address - City:CORONA
Mailing Address - State:CA
Mailing Address - Zip Code:92879-8099
Mailing Address - Country:US
Mailing Address - Phone:951-532-0514
Mailing Address - Fax:
Practice Address - Street 1:12155 MAGNOLIA AVE STE 3G
Practice Address - Street 2:
Practice Address - City:RIVERSIDE
Practice Address - State:CA
Practice Address - Zip Code:92503-4969
Practice Address - Country:US
Practice Address - Phone:951-532-0514
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-02-22
Last Update Date:2021-11-15
Deactivation Date:2018-05-03
Deactivation Code:
Reactivation Date:2018-05-16
Provider Licenses
StateLicense IDTaxonomies
CA116203106H00000X
CAIMF80647106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist