Provider Demographics
NPI:1205410834
Name:SPULECKI, THERESA
Entity Type:Individual
Prefix:
First Name:THERESA
Middle Name:
Last Name:SPULECKI
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 1:2211 E OCEAN BLVD
Mailing Address - Street 2:
Mailing Address - City:LONG BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:90803-2440
Mailing Address - Country:US
Mailing Address - Phone:562-434-4060
Mailing Address - Fax:562-457-3621
Practice Address - Street 1:2211 E OCEAN BLVD
Practice Address - Street 2:
Practice Address - City:LONG BEACH
Practice Address - State:CA
Practice Address - Zip Code:90803-2440
Practice Address - Country:US
Practice Address - Phone:562-434-4060
Practice Address - Fax:562-457-3621
Is Sole Proprietor?:No
Enumeration Date:2021-05-10
Last Update Date:2021-05-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAR1429350521101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)