Provider Demographics
NPI:1679620264
Name:TELLEEN, CHRISTINE C (MA)
Entity Type:Individual
Prefix:MS
First Name:CHRISTINE
Middle Name:C
Last Name:TELLEEN
Suffix:
Gender:F
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:701 LAURELWOOD DR
Mailing Address - Street 2:
Mailing Address - City:SAN MATEO
Mailing Address - State:CA
Mailing Address - Zip Code:94403-4029
Mailing Address - Country:US
Mailing Address - Phone:650-341-9437
Mailing Address - Fax:
Practice Address - Street 1:100 S ELLSWORTH AVE
Practice Address - Street 2:303
Practice Address - City:SAN MATEO
Practice Address - State:CA
Practice Address - Zip Code:94401-3939
Practice Address - Country:US
Practice Address - Phone:650-579-4470
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-01-04
Last Update Date:2017-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAAU372231H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes231H00000XSpeech, Language and Hearing Service ProvidersAudiologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CABU187YOtherMEDICARE PTAN FOR PENINSULA MEDICAL CLINIC
CABU187YOtherMEDICARE PTAN FOR PENINSULA MEDICAL CLINIC
CAZZZ308962Medicare ID - Type Unspecified