Provider Demographics
NPI:1093767204
Name:CHOI BAE, THERESIA (LICENSE PSYCHOLOGIS)
Entity Type:Individual
Prefix:
First Name:THERESIA
Middle Name:
Last Name:CHOI BAE
Suffix:
Gender:F
Credentials:LICENSE PSYCHOLOGIS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15350 SHERMAN WAY STE 200
Mailing Address - Street 2:
Mailing Address - City:VAN NUYS
Mailing Address - State:CA
Mailing Address - Zip Code:91406-4458
Mailing Address - Country:US
Mailing Address - Phone:818-267-1100
Mailing Address - Fax:
Practice Address - Street 1:15350 SHERMAN WAY STE 200
Practice Address - Street 2:
Practice Address - City:VAN NUYS
Practice Address - State:CA
Practice Address - Zip Code:91406-4458
Practice Address - Country:US
Practice Address - Phone:818-267-1100
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-05-16
Last Update Date:2022-07-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CALCS232861041C0700X
225400000X, 225C00000X, 390200000X
CA33325103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No225400000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRehabilitation Practitioner
No225C00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRehabilitation Counselor
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
CALCS23286Medicare ID - Type UnspecifiedCLINICAL SOCIAL WORKER