Provider Demographics
NPI:1619929445
Name:GEORGE, TERESA MARIE (PHD)
Entity Type:Individual
Prefix:
First Name:TERESA
Middle Name:MARIE
Last Name:GEORGE
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3940-7 BROAD STREET, PMB #305
Mailing Address - Street 2:
Mailing Address - City:SAN LUIS OBISPO
Mailing Address - State:CA
Mailing Address - Zip Code:93401
Mailing Address - Country:US
Mailing Address - Phone:805-971-0131
Mailing Address - Fax:805-926-2162
Practice Address - Street 1:3925 IMEL RD
Practice Address - Street 2:
Practice Address - City:SAN LUIS OBISPO
Practice Address - State:CA
Practice Address - Zip Code:93401-6238
Practice Address - Country:US
Practice Address - Phone:805-710-3199
Practice Address - Fax:805-262-6206
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-17
Last Update Date:2022-02-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY16121103TF0200X, 103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No103TF0200XBehavioral Health & Social Service ProvidersPsychologistForensic
Provider Identifiers
StateIdentifier IDID TypeIssuer
OPL161210Medicare ID - Type Unspecified
P44009Medicare UPIN