Provider Demographics
NPI:1619000528
Name:TELLEZ, GEORGE
Entity Type:Individual
Prefix:
First Name:GEORGE
Middle Name:
Last Name:TELLEZ
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:555 REDDINGTON DR
Mailing Address - Street 2:
Mailing Address - City:REDDING
Mailing Address - State:CA
Mailing Address - Zip Code:96003-5217
Mailing Address - Country:US
Mailing Address - Phone:530-222-7695
Mailing Address - Fax:530-225-5232
Practice Address - Street 1:2640 BRESLAUER WAY
Practice Address - Street 2:
Practice Address - City:REDDING
Practice Address - State:CA
Practice Address - Zip Code:96001-4246
Practice Address - Country:US
Practice Address - Phone:530-245-6421
Practice Address - Fax:530-225-5232
Is Sole Proprietor?:No
Enumeration Date:2007-03-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA0163101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)