Provider Demographics
NPI:1568675973
Name:TEAL, KATHLEEN MARGARET (MFT)
Entity Type:Individual
Prefix:
First Name:KATHLEEN
Middle Name:MARGARET
Last Name:TEAL
Suffix:
Gender:F
Credentials:MFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:75 DECLARATION DR STE 7
Mailing Address - Street 2:
Mailing Address - City:CHICO
Mailing Address - State:CA
Mailing Address - Zip Code:95973-4928
Mailing Address - Country:US
Mailing Address - Phone:530-892-9772
Mailing Address - Fax:530-892-2900
Practice Address - Street 1:75 DECLARATION DR STE 7
Practice Address - Street 2:
Practice Address - City:CHICO
Practice Address - State:CA
Practice Address - Zip Code:95973
Practice Address - Country:US
Practice Address - Phone:530-892-9772
Practice Address - Fax:530-892-2900
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-08
Last Update Date:2018-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAMFC40468106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA1568675973Medicaid