Provider Demographics
NPI:1073644878
Name:KJELDGAARD, THERESA A (MA, MFT)
Entity Type:Individual
Prefix:
First Name:THERESA
Middle Name:A
Last Name:KJELDGAARD
Suffix:
Gender:F
Credentials:MA, MFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14535 SHERMAN CIR
Mailing Address - Street 2:
Mailing Address - City:VAN NUYS
Mailing Address - State:CA
Mailing Address - Zip Code:91405-3087
Mailing Address - Country:US
Mailing Address - Phone:818-901-4930
Mailing Address - Fax:
Practice Address - Street 1:14535 SHERMAN CIR
Practice Address - Street 2:
Practice Address - City:VAN NUYS
Practice Address - State:CA
Practice Address - Zip Code:91405-3087
Practice Address - Country:US
Practice Address - Phone:818-901-4930
Practice Address - Fax:818-785-3147
Is Sole Proprietor?:No
Enumeration Date:2007-03-07
Last Update Date:2013-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAMFC39308106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist