Provider Demographics
NPI:1346886678
Name:ISIDRO, THERESA MARIE
Entity Type:Individual
Prefix:
First Name:THERESA
Middle Name:MARIE
Last Name:ISIDRO
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 1:500 DAVIS ST STE 100
Mailing Address - Street 2:
Mailing Address - City:SAN LEANDRO
Mailing Address - State:CA
Mailing Address - Zip Code:94577-2758
Mailing Address - Country:US
Mailing Address - Phone:510-618-6427
Mailing Address - Fax:
Practice Address - Street 1:500 DAVIS ST STE 100
Practice Address - Street 2:
Practice Address - City:SAN LEANDRO
Practice Address - State:CA
Practice Address - Zip Code:94577-2758
Practice Address - Country:US
Practice Address - Phone:510-618-6427
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-11-21
Last Update Date:2019-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CALMFT112806101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health