Provider Demographics
NPI:1033621511
Name:THEODORE, ZLATENA (PSYD)
Entity Type:Individual
Prefix:
First Name:ZLATENA
Middle Name:
Last Name:THEODORE
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3639 HAVEN AVE APT B218
Mailing Address - Street 2:
Mailing Address - City:MENLO PARK
Mailing Address - State:CA
Mailing Address - Zip Code:94025-1010
Mailing Address - Country:US
Mailing Address - Phone:773-905-4701
Mailing Address - Fax:
Practice Address - Street 1:311 CALIFORNIA ST
Practice Address - Street 2:
Practice Address - City:SAN FRANCISCO
Practice Address - State:CA
Practice Address - Zip Code:94104-2602
Practice Address - Country:US
Practice Address - Phone:773-905-4701
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-10-24
Last Update Date:2017-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY29312103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical