Provider Demographics
NPI:1053200600
Name:TEYUCA, EDVINO DE JESUS
Entity type:Individual
Prefix:
First Name:EDVINO
Middle Name:DE JESUS
Last Name:TEYUCA
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1936 CYPRESS AVE APT 8
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90065-1360
Mailing Address - Country:US
Mailing Address - Phone:213-864-1718
Mailing Address - Fax:
Practice Address - Street 1:536 S 2ND AVE STE D
Practice Address - Street 2:
Practice Address - City:COVINA
Practice Address - State:CA
Practice Address - Zip Code:91723-3043
Practice Address - Country:US
Practice Address - Phone:213-864-1718
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-06-30
Last Update Date:2025-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)