Provider Demographics
NPI:1629414735
Name:STEVENSON, TERESA (PHD)
Entity Type:Individual
Prefix:DR
First Name:TERESA
Middle Name:
Last Name:STEVENSON
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 1:9102 GENERATIONS DR
Mailing Address - Street 2:
Mailing Address - City:ELK GROVE
Mailing Address - State:CA
Mailing Address - Zip Code:95758-1202
Mailing Address - Country:US
Mailing Address - Phone:310-903-9620
Mailing Address - Fax:
Practice Address - Street 1:4001 CALIFORNIA HIGHWAY 104
Practice Address - Street 2:
Practice Address - City:IONE
Practice Address - State:CA
Practice Address - Zip Code:95640
Practice Address - Country:US
Practice Address - Phone:209-274-4911
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-05-15
Last Update Date:2013-07-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY13847103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical