Provider Demographics
NPI:1528217049
Name:TELLER, BEVERLY ANN (BEVERLY TELLER MFT)
Entity Type:Individual
Prefix:
First Name:BEVERLY
Middle Name:ANN
Last Name:TELLER
Suffix:
Gender:F
Credentials:BEVERLY TELLER MFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1730 W VERDUGO AVE
Mailing Address - Street 2:
Mailing Address - City:BURBANK
Mailing Address - State:CA
Mailing Address - Zip Code:91506-2148
Mailing Address - Country:US
Mailing Address - Phone:818-470-6241
Mailing Address - Fax:
Practice Address - Street 1:18321 VENTURA BLVD
Practice Address - Street 2:SUITE 515
Practice Address - City:TARZANA
Practice Address - State:CA
Practice Address - Zip Code:91356-4228
Practice Address - Country:US
Practice Address - Phone:818-754-8252
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-09-09
Last Update Date:2008-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAMFC 44085106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist